hinchingbrooke health care nhs trust hinchingbrooke hospital

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we foundwhen we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, thepublic and other organisations.

Ratings

Overall rating for this hospital Inadequate –––

Urgent and emergency services Inadequate –––

Medical care Inadequate –––

Surgery Requires improvement –––

Critical care Good –––

Maternity and gynaecology Good –––

End of life care Requires improvement –––

Outpatients and diagnostic imaging Good –––

Hinchingbrooke Health Care NHS Trust

HinchingbrHinchingbrookookee HospitHospitalalQuality Report

Hinchingbrooke ParkHinchingbrookeHuntingdonCambridgeshirePE29 6NTTel: 01480 416416Website: www.hinchingbrooke.nhs.uk

Date of inspection visit: 16 - 18 Sept, Unannouncedvisits on 21 and 28 Sept 2014Date of publication: 09/01/2015

1 Hinchingbrooke Hospital Quality Report 09/01/2015

Letter from the Chief Inspector of Hospitals

The Care Quality Commission (CQC) carried out a comprehensive inspection which included an announced inspectionvisit between the 16 and 18 September 2014 and subsequent unannounced inspection visits on 21 and 28 September.We carried out this comprehensive inspection of the acute core services provided by the trust as part of Care QualityCommission’s (CQC) new approach to hospital inspection.

Hinchingbrooke Hospital is an established 304 bed general hospital, which provides healthcare services to NorthCambridge and Peterborough. The trust provides a comprehensive range of acute and obstetrics services, but does notprovide inpatient paediatric care, as this is provided within the location by a different trust. The trust is the onlyprivately-managed NHS trust in the country, being managed by Circle since 2012.The Trust's governance is derived fromthe Franchise Agreement and Intervention Order approved by the Secretary of State for Health. This approachempowers all members of staff to take accountability and responsibility for the planning and implementing of a highquality service.

Prior to undertaking this inspection we spoke with stakeholders and reviewed the information we held about the trust.Hinchingbrooke Health Care NHS Trust had been identified as low risk on the Care Quality Commission’s (CQC)Intelligent Monitoring system. The trust was in band 6, which is the lowest band.

The hospital was first built in the 1980s. It was the first trust in the country to be managed by an independent healthcarecompany, Circle, which occurred in February 2012. It is led by a multidisciplinary team of clinical and non-clinicalexecutives partnered with a non-executive Trust Board.However we found that the trust was predominantly medicallyled but a new director of nursing had been appointed four months prior to our visit and was beginning to address theinput of nursing within the hospital.

We found significant areas of concern during our inspection visit which we raised with the chief executive, director ofnursing, head of midwifery and the chief operating officer of the trust and the next day with the NHS Trust DevelopmentAuthority. We were concerned about patients safety and referred a number of patients to the Local Authoritysafeguarding team. Since the inspection the Trust Development Authority have given the trust significant support toaddress the issues raised in this report. CQC served a letter which informed the trust of the nature of our concerns inorder that action could be taken in a timely manner. CQC also requested further information from the trust as weconsidered taking urgent action to reduce the number of beds available on Apple Tree Ward. However the trust took thedecision to reduce the number of beds as part of their action plan and so this regulatory action was therefore notnecessary. The matter has been kept under review and the CQC has undertaken two unannounced inspections,attended the Annual Public Meeting [i.e. the Annual General Meeting] on 25 September 2014 and held two follow upmeetings with the trust to ensure that action have been taken.

The comprehensive inspections result in a trust being assigned a rating of ‘outstanding’, ‘good’, ‘requires improvement’or ‘inadequate’. Each core service receives an individual rating, which, in turn, informs an overall trust rating. Theinspection found that overall; the trust has a rating of 'inadequate'.

Our key findings were as follows:

• We found many instances of staff wishing to care for patients in the best way, but unable to raise concerns or preventservice demands from severely impinging on the quality and kindness of care for patients. In both maternity andcritical care we noted good care, focused on patients’ needs, meeting national standards.

• The provision of care on Apple Tree Ward, a medical ward, was inadequate and there were risks to patient safety. Thisrequired urgent action to address the concerns of the inspection team.

• There was a lack of paediatric cover within the A&E department and theatres that meant that the care of children inthese departments was, at times,increasing potential risks to patient safety.

Summary of findings


• The senior management team of the trust are well known within the hospital; however, the values and beliefs of thetrust were not embedded, nor were staff engaged or empowered to raise concerns by taking responsibility to 'Stopthe Line'. Stop the line is a process which empowers all members of staff to raise immediate concerns when theybelieve that patient safety is being compromised. Initiating a "Stop the Line" facilitates management support to thearea identified and action to address the issue.

• There was a lack of knowledge around Adult Safeguarding procedures, Mental Capacity Act and Deprivation ofLiberty processes.

• A response to call bells in a number of areas, in Juniper Ward, Apple Tree ward and the Reablement Unit for example,was so poor that two patients of the 53 we spoke to in the medical and surgical areas stated that they had been toldto soil themselves. A further one patient advised that they had soiled themselves whilst awaiting assistance. Webrought this to the attention of the trust and they investigated. However neither CQC nor the trust could corroboratethese claims.

• Risk assessments were not always reflective of the needs of patients in surgery and medical wards. This wasevidenced by review of 46 sets of notes of which 19 were found to have incomplete information or review.

• Infection control practices were not always complied with in A&E Apple Tree ward, Cherry Tree ward, Walnut wardand in the Treatment Centre.

• Medicines, including controlled drugs, were not always stored or administered appropriately in A&E, Juniper ward,Apple Tree ward or Cherry Tree ward.

We saw several areas of good practice including:

• In both maternity and critical care we noted good care, focused on patients’ needs, meeting national standards.• The paediatric specialist nurse in the emergency department was dynamic and motivated in supporting children and

parents. This was seen through the engagement of children in the local community, in a project to develop anunderstanding of the hospital from a child’s perspective, through the '999 club'.

• The support that the chaplaincy staff gave to patients and hospital staff was outstanding. The chaplain had a goodrelationship with the staff, and was considered one of the team. The number of initiatives set up by the chaplain tosupport patients was outstanding.

However, there were also areas of poor practice, where the trust needs to make improvements.

Importantly, the trust must:

• Ensure all patients health and safety is safeguarded, including ensuring that call bells are answered in order to meetpatients’ needs in respect of dignity, and patient’s nutrition and hydration needs are adequately monitored andresponded to.

• Ensure that staffing levels and skill mix on wards is reviewed and the high usage of agency and bank staff to ensurethat numbers and competencies are appropriate to deliver the level of care Hinchingbrooke Hospital requires.

• Ensure that the arrangements for the provision of services to children in A&E, operating theatres and outpatientsareas provided by the trust, is reviewed to ensure that it meets their needs, and that staff have the appropriatesupport to raise issues on the service provision.

• Ensure records, including risk assessments, are completed, updated and reflective of the needs of patients.• Ensure the care pathways, including peadiatric pathways, in place are consistently followed by staff.• Ensure an adequate skill mix in the emergency department and theatres to ensure that paediatric patients receive a

service that meets their needs in a timely manner.• Ensure that there are sufficient appropriately skilled nursing staff on medical and surgical wards to meet patients’

needs in a timely manner.• Ensure medicines are stored securely and administered correctly.• Improve infection control measures in the Emergency department and medical wards to protect patients from

infection through cross contamination.

Summary of findings


• Ensure staff are trained in, and have knowledge of their responsibilities under the Mental Capacity Act (MCA) 2005and Deprivation of Liberty Safeguards (DoLS).

• Ensure that patients are treated with dignity and respect.• Ensure that all staff are adequately supported through appraisal, supervision and training to deliver care to patients.• Ensure pressure ulcer care is consistently provided in accordance with National Institute for Health and Care

Excellence (NICE) guideline CG:179.• Ensure that catheter and intravenous (IV) care is undertaken in accordance with best practice guidelines.• Ensure patients are treated in accordance with the Mental Capacity Act 2005.• Ensure that the staff to patient ratio is adjusted to reflect changing patient dependency.• Review the ‘Stop the Line’ procedures and whistle blowing procedures, to improve and drive an open culture within

the trust.• Standardise and improve the dissemination of lessons learnt from incidents to support the improvement of the

provision of high quality care for all patients.• Ensure that all appropriate patients receive timely referral to the palliative care service.• Ensure action is taken to improve the communication with patients, to ensure that they are involved in

decision-making in relation to, their care treatment, and that these discussions are reflected in care plans.• Review mechanisms for using feedback from patients, so that the quality of service improves.

In addition, the trust should:

• Review the checking of resuscitation equipment in the A&E department, and across the trust, to ensure that it occursas per policy.

• Take action to reduce the overburdensome administration processes when admitting patients into the acuteassessment unit (AAU).

• Review intentional rounding checks to ensure that they cover requirements for meeting patient’s nutrition andhydration needs.

• Involve patients in making decisions about their care in the A&E department.• Review the training given to staff, and the environment provided, for having difficult discussions with patients.• Review translation usage in A&E, to ensure that patients receive information appropriate to their needs.• Provide adequate training on caring for patients living with dementia, to improve the service to patients living with

dementia.• Discontinue the practice of adapting day rooms in rehabilitation wards to use as additional inpatient bed spaces.• Review the clinical pathways for termination of pregnancies in the acute medical area.• Review the policy on moving patients late at night.• Review the out-of-hours arrangements for diagnostic services, such as radiology and pathology, to ensure that

patients receive a timely service.• Review mechanisms for fast track discharge, so that terminally ill patients die in a place of their choice.

Professor Sir Mike RichardsChief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Why have we given this rating?Urgent andemergencyservices

Inadequate ––– The emergency department at HinchingbrookeHospital was inadequate in respect of the safe andwell-led domains. We could not be assured thatthere were sufficient assurance processes in placeto demonstrate that patients were not at high riskof harm when we inspected.There was minimalincident reporting and recording within theemergency department. We could not see thatcompleted incident reports had a clear ‘lessonslearnt’ approach. We looked at equipment whichwas visibly clean, but found that some equipmentwas not maintained to the manufacturer’srecommendations with service labels highlightingthat a service was due. Medication was not securelystored appropriately, and daily checks onemergency resuscitation trollies were not carriedout by staff. Staff vacancies were covered with bankand agency staff which accounted for over a quarterof the staff numbers. Paediatric cover for children inthis department was not sufficient to cover 24hours, and staff did not have the competency tocare for children when paediatric nurses were noton duty. Since our visit the trust has employedpeadiatric agency and bank staff to cover 24 hours.Clinical outcomes and monitoring of the serviceshowed that the trust was not outliers whencompared to others however we found that theprovision of care was not assured by the leadership,governance or culture in place during ourinspection. Patients were routinely triaged withinthe waiting room area with no consideration fortheir privacy or dignity. This practice was not in linewith departmental expectations; the trust doesprovide a private room suitable for triage andexpects staff to offer patients a choice. There was asenior member of nursing staff who was designatedas a shift co-ordinator, and we found that thepriorities and management of the department wereweak. When busy, two staff told inspectors that theyaccepted that they could not give the care that theywould wish to do so. We heard one patient requestassistance and a member of staff told them that

Summaryoffindings

Summary of findings


they did not have time but would return. Howeverafter 30 minutes the patient stated that no one hadreturned. We raised this issue to a member of staffwho assisted the patient.The department was not responsive to the needs ofall of the people who used it. Children had noseperate waiting area and treatment roomsdesigned for children were not always used forthem. There were higher than the England averagenumber of people who left the department beforebeing seen due to long waiting times and those whowere to be admitted also spent considerablelengths of time in the department. The escalationprotocol was not used effectively to reduce patientswaiting timesMental capacity assessments were beingundertaken appropriately, and staff demonstratedknowledge around most of the trust’s policy andprocedures. We saw that staff were rushed withtheir workload, but took the time to listen topatients, and explain to them what was wrong andany treatment required. The staff we spoke withwere proud to work in the emergency department.

Medical care Inadequate ––– Medical services were inadequate because wefound poor emotional and physical care which wasnot safe or caring. This was not reported by leadersof the service to the trust management therefore wejudged the leadership to be inadequate. Serviceswere not caring because people were not treatedwith dignity or respect. We were also concernedthat people were not being treated in anemotionally supportive manner. Hand hygiene andinfection control techniques were poor. Staffingnumbers were not always reflective of patientdependency. Examples of treatment withoutconsent were identified on one patient who lackedmental capacity but we found an under recognitionof patients who may lack capacity throughout themedical wards. Services were not effective becausepressure ulcer prevention and treatment was notalways provided in line with NICE guidelines. Therewere no seven day services provided by thehospital. The service was not responsive; we foundthat medical patients were not always classed asoutliers despite requiring specialised care. This

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Summary of findings


meant that the frequency of review by their ownconsultant might be reduced. The Medical ShortStay Unit and the Reablement Centre were notutilised for their intended purpose.The service was not well-led. We found that theculture of identifying, reporting and escalatingconcerns was not open. We found that teams werenot engaged or felt enabled to raise concerns. Wewrote to the trust to express our concerns and withthe support of the Trust Development Authorityaction underway to address these.

Surgery Requires improvement ––– The surgical services require improvement becausethere were significant risks and deficiencies evidentacross four areas of our inspection domains. Thesafety of patients was at risk due to delays in nursesattending when patients call for help. In JuniperWard there was a clear consensus from manypatients that they were not cared for safely becauseit took too long for nurses to respond, in particularat night time.However the trust produced datawhich demonstrated that the average responsetime in the week prior to our visit was on averagefour minutes, this meant that this may have beenan emerging issue. We found that there werecontinuing problems of medication not beingadministered as prescribed. Nursing care recordsand plans did not always reflect the current needsof the patient, or have clear guidance of the care tobe provided.Patient outcomes were good in certain respects,such as low incidence of pressure ulcers, and lowreadmission rates indicating successful overalltreatment. Many issues were evident and had beenidentified by the trust, but action had not beentaken to improve the issues or actions taken hadnot been effective. It was not evident that staffcould easily raise issues they were concernedabout, either in their own teams or acrossprofessional boundaries.

Critical care Good ––– Critical care services were good overall. We foundthat services were safe, as competent medical,nursing and other professionals worked effectivelytogether to ensure safety. The environment wascramped and old, which meant that staff had towork flexibly and efficiently to ensure cleanliness,

Summaryoffindings

Summary of findings


safety, and privacy and dignity for patients. Theservice is effective as staff followed clinicalguidance and locally agreed protocols.Performance data showed that there were fewincidents of harm.The service was caring as patients and relatives toldus that staff were very supportive. There weresystems available to provide follow-up emotionalsupport if required. Critical care services wereresponsive because a range of detailed assessmentrecords were used to prompt staff to meet patients'individual needs. Children were cared for in theCritical Care Centre, but this was a temporarymeasure to provide urgent support until specialistcare was arranged. The service was well-led, as staffworked well as an integrated team to provide veryspecialist care within the unit, and also to patientsrequiring aspects of intensive care in other wardareas. Audit work was established by the outreachstaff to monitor the overall management ofdeteriorating patients in all wards.

Maternityandgynaecology

Good ––– The current level of maternity services provided towomen and babies by Hinchingbrooke Hospitalwere good. The maternity unit provided safestaffing levels and skill mix, and encouragedproactive teamwork to support a safe environment.We saw that there were arrangements in place toimplement good practice, learning from anyuntoward incidents, and an open culture toencourage a focus on patient safety and riskmanagement practices.The trust is working towardsachievement of Level 2 Unicef's Baby FriendlyInitiativeAll permanent staff were appropriately qualifiedand competent to carry out their roles safely andeffectively in line with best practice. There weredetailed and timely multidisciplinary teamdiscussions and handovers, to ensure women andbabies care and treatment was co-ordinated andthe expected outcomes were achieved. Staff in allroles put effort into treating women with dignity,and most women felt well-cared for as a result. Staffin the hospital and community were flexible inworking practices and responding to the needs ofwomen and babies. We found the midwiferyleadership model encouraged co-operative,

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Summary of findings


supportive relationships among staff. Staff reportedthat the managers and supervisors ensured thatthey felt respected, valued, supported and caredfor. Staff contributions and performance wererecognised and celebrated.

End of lifecare

Requires improvement ––– End of life care service require improvements aspatients are at risk of not receiving safe or effectivetreatment that meets their needs. Do notresuscitate forms were not completed correctly, thepalliative care team were over stretched whichmeant that staff were not effectively trained andpatients did not receive the levels of care they couldexpect. These risks were not recorded on a riskregister as there was not one specific to end of lifecare. We were told that there were no associatedend of life care risks.'Do not attempt cardio-pulmonary resuscitation'(DNA CPR) forms were completed, but a highpercentage had not been appropriately signed by aconsultant. In many instances, we found that DNACPR decisions had not been discussed with thepatient or their representatives. Assessments hadnot been completed when the reason given for notdiscussing decisions with patients was recorded asthe patient lacking capacity. Documentation wasfound to be poor throughout the service. Ward stafftraining in end of life care was lacking, and no onewe spoke to on the wards had advancedcommunication training, however the palliativecare team did have this training.The specialist palliative care team was well-led, andhad worked hard to improve end of life carethroughout the hospital. The team had put togethera business case to increase staffing within the team,in order to ensure that they could provide anequitable, effective and safe end of life care service,that was available 24 hours every day. Thechaplaincy service provided outstanding care topatients and support to the nursing staff on wards.Most of the hospital wards were providing end oflife care and therefore this report should be read inconjunction with the medical care report.

Summaryoffindings

Summary of findings


Outpatientsanddiagnosticimaging

Good ––– We found outpatients to be safe. Medicines andprescription pads were securely stored, althoughwe found a small amount of medicines within thetrauma and orthopaedic outpatient clinic, whichwere being stored along with cleaning fluids andother items. The outpatient areas we visited wereclean, and equipment was well maintained. Staffvacancies were being managed appropriately.Patients were appropriately asked for their consentto procedures. On most occasions records wereavailable for patient clinic appointments.The service in outpatients was caring. Patientsreceived compassionate care, and were treatedwith dignity and respect. The outpatient servicewas responsive to people’s individual needs.Patients were seen within national waiting times.Staff told us that clinics were rarely cancelled.Translation services were available for people whodid not speak English, and all the staff we askedabout this were able to tell us how to access theseservices. Complaints were handled appropriately,and action was taken to improve the service.Outpatient services were well-led and there wasgood local leadership of clinics. Patient feedbackwas used to improve the service, and there wasinnovation in some service areas, such as one-stopclinics in gynaecology.

Summaryoffindings

Summary of findings


Contents

PageDetailed findings from this inspectionBackground to Hinchingbrooke Hospital 11

Our inspection team 12

How we carried out this inspection 12

Facts and data about Hinchingbrooke Hospital 13

Our ratings for this hospital 15

Findings by main service 16

Action we have told the provider to take 94

Background to Hinchingbrooke Hospital

Hinchingbrooke Hospital is an established 304 bedgeneral hospital, which provides healthcare services toNorth Cambridge and Peterborough. The hospitalprovides a comprehensive range of acute and obstetrics

services. The trust does not provide general inpatientpaediatric care, as this is provided within the location bya different trust. However children are seen in the A&Edepartment, operating theatres and in outpatients byHinchingbrooke Health Care NHS Trust staff. The trust isthe only privately-managed NHS trust in the country,being managed by Circle since 2012.The Trust'sgovernance is derived from the Franchise Agreement andIntervention Order approved by the Secretary of State for

Health. This approach is intended to empower allmembers of staff to take accountability and responsibilityfor the planning and implementing of a high qualityservice.

The average proportion of Black, Asian and minorityethnic (BAME) residents in Cambridgeshire (5.2%) is lowerthan that of England (14.6%). The deprivation index islower than the national average, implying that this is nota deprived area. However, Peterborough has a higherBAME population and a higher deprivation index.

The Care Quality Commission (CQC) carried out acomprehensive inspection which included an announced

HinchingbrHinchingbrookookee HospitHospitalalDetailed findings

Services we looked atAccident and emergency; Medical care (including older people’s care); Surgery; Critical care; Maternity and

family planning; End of life care; Outpatients

Inadequate –––


inspection visit between the 16 and 18 September 2014and subsequent unannounced inspection visits on 21

and 28 September and attended the Annual PublicMeeting on 25 September 2014. The trust had beenidentified as a low risk through CQC's intelligencemonitoring.

Our inspection team

Our inspection team was led by:

Chair: Jonathan Fielden, Medical Director, UniversityCollege London Hospitals

Head of Hospital Inspections: Fiona Allinson, CareQuality Commission

The team included CQC inspectors and a variety ofspecialists: nine CQC inspectors, one medical director, ahead of governance, six medical consultants, one juniordoctor, six senior nurses, a student nurse, and two'experts by experience'. (Experts by experience havepersonal experience of using or caring for someone whouses the type of service that we were inspecting.)

How we carried out this inspection

To get to the heart of patients’ experiences of care, wealways ask the following five questions of every serviceand provider:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

The announced inspection visit took place between the16 and 18 September 2014, with subsequentunannounced inspection visits on 21 and 28 Septemberand attended the Annual Public Meeting on 25September 2014

Before visiting, we reviewed a range of information weheld, and asked other organisations to share what theyknew about the hospital. These included the clinicalcommissioning group (CCG); Monitor; NHS England;Health Education England (HEE); General Medical Council(GMC); Nursing and Midwifery Council (NMC); RoyalCollege of Nursing; College of Emergency Medicine; RoyalCollege of Anaesthetists; NHS Litigation Authority;Parliamentary and Health Service Ombudsman; RoyalCollege of Radiologists and the local Healthwatch.

We held a listening event on 16 September 2014, whenpeople shared their views and experiences ofHinchingbrooke Hospital. Some people who were unableto attend the listening event shared their experienceswith us via email or by telephone.

We carried out an announced inspection visit between 16and 18 September 2014. We spoke with a range of staff inthe hospital, including nurses, junior doctors,consultants, administrative and clerical staff, radiologists,radiographers and pharmacists. We also spoke with staffindividually as requested. We carried out unannouncedvisits on Sunday 21 September to Apple Tree Ward,Thursday 25 September to the Annual Public Meeting,and Saturday 28 September 2014 to the emergencydepartment, Juniper and Apple Tree Wards. During theseunannounced visits we spoke with staff, patients andrelatives.

We talked with patients and staff from all the ward areasand outpatient services. We observed how people werebeing cared for, talked with carers and/or familymembers, and reviewed patients’ records of personalcare and treatment.

We would like to thank all staff, patients, carers and otherstakeholders for sharing their views and experiences ofthe quality of care and treatment at HinchingbrookeHospital.

Detailed findings


Facts and data about Hinchingbrooke Hospital

Beds

304 (260 General and acute, 38 Maternity and 6 Criticalcare)

Inpatient admissions

Outpatient attendances 93,000 (2012/13)

A+E attendances 38,813 (2013/14)

Births 2,193 births April 2013 March 2014

Deaths 493 (April 2013 – March 2014) 102 (April 2014 –June 2014)

Annual turnover £111.5m

Surplus (deficit) -£1m

Intelligent MonitoringElevated risk scores in well led 1

Risk score in well led 1

Total risk score 3

Individual risks/elevated risks

• NHS Staff Survey - KF7. The proportion of staff who wereappraised in last 12 months (01-Sep-13 to 31-Dec-13)

By DomainSafe

Never events (April 2013 -May 2014) 0

Serious incidents (STEIs) (April 2013- May 2014) 41

National reporting and learning system (NRLS) (April2013- May 2014)

Deaths 5, Severe 31, Moderate 86 Total 122

Effective:

HSMR: IM Indicator: No evidence of risk

SHMI: IM Indicator: No evidence of risk

Caring:

CQC inpatient survey 2013:

The trust scored average for all 10 sections.

• In Subsection 4: The hospital and ward the trust scoredbelow average question 19. Did you feel threatenedduring your stay in hospital by other patients or visitors?

Cancer patient experience survey 2012/13:

Of all 68 questions the trust scored

• In the highest 20% of all Trusts for 6 questions• In the lowest 20% of all Trusts for 8 questions

Responsive:

Bed occupancy: In Q1 2014 the trusts average daily bedoccupancy for all General and Acute beds was 82.7%which is less than both the England average of 89.5% andthe 85% percent standard where it is suggested level ofpatient care would be affected.

length of stay:

April 2013 to March 2014

• Elective▪ Trust Average = 4 days▪ England Average = 4 days

• Non-Elective▪ Trust Average = 6 days▪ England Average = 7 days

A+E: 4 hour standard:

IM Indicator: Composite indicator: A&E waiting timesmore than 4 hours (05-Jan-14 to 30-Mar-14) - No evidenceof risk April 2014 – May 2014

• Average A&E 4 hour waiting time target is 96%

Out of 52 weeks which ended in 2013/14, the trust missedthe 95% target 13 times. Hinchingbrooke was above theEngland average in 38 of 52 weeks, or 73% of the time.However the current year to date figure is just over 95%which is in line with the expected average.

Cancelled operations:The proportion of patients whoseoperation was cancelled (01-Jan-14 to 31-Mar-14) - Noevidence of risk

18 week RTT

IM Indicator: Composite indicator: Referral to treatment(01-Mar-14 to 31-Mar-14) - No evidence of risk April 2013 –March 2014

Detailed findings


• 18 week RTT consistently above operational standard of90%

Well led:

Staff survey

Of all 28 questions the trust scored

• Above average for all NHS Trusts for 2 questions• Below average for all NHS Trusts for 13 questions

Sickness rate

IM Indicator: Composite risk rating of ESR items relatingto staff sickness rates (01-Apr-13 to 31-Mar-14) - Noevidence of risk April 13 – Dec 13

• Average Trust sickness rate was 4.2% while that forEngland was 4%

The trust’s average sickness rate was greater than that forEngland for seven out of nine months.

GMC Training Survey 2014: Out of 12 survey areas thetrust scored within the interquartile range (so aboutaverage) for 11, but was significantly worse than expectedfor one area, which was Feedback.

GMC - Enhanced monitoring (01-Mar-09 to 21-Apr-14)

Detailed findings


Our ratings for this hospital

Our ratings for this hospital are:

Safe Effective Caring Responsive Well-led Overall

Urgent and emergencyservices Inadequate Not rated Requires

improvementRequires

improvement Inadequate Inadequate

Medical care Inadequate Requiresimprovement Inadequate Requires


Surgery Requiresimprovement

Requiresimprovement Inadequate Good Requires

improvementRequires

improvement

Critical care Good Good Good Good Good Good

Maternity andgynaecology Good Good Good Good Good Good

End of life care Requiresimprovement

Requiresimprovement Good Good Good Requires

improvement

Outpatients anddiagnostic imaging Good Not rated Good Good Good Good

Overall Inadequate Requiresimprovement Inadequate Requires


Notes<Notes here>

Detailed findings


Safe Inadequate –––

Effective Not sufficient evidence to rate –––

Caring Requires improvement –––

Responsive Requires improvement –––

Well-led Inadequate –––

Overall Inadequate –––

Information about the serviceThe emergency department (ED) at HinchingbrookeHospital provides a 24 hour, seven day a week service tothe local area. Patients present to the department eitherby walking into the department via the reception area, orarriving by ambulance. The department has facilities forassessment, treatment of minor and major injuries, aresuscitation area and a children’s provision ED service.There is an acute assessment unit (AAU) within the samedirectorate, for which patients are admitted for up to 24hours.

Our inspection included two days in the emergencydepartment as part of an announced inspection, and anunannounced visit on Sunday 27 September 2014. Duringour inspection, we spoke with clinical leads from medicaland nursing disciplines for the department. We spokewith six members of the medical team (of various levels ofseniority), seven members of the nursing team (of variouslevels of seniority) and administration staff. Theemergency department sees, on average, just over 100patients in any given day. During our inspection, wespoke with 13 patients and undertook generalobservations within all areas of the department. Wereviewed the medication administration and patientrecords for patients in the emergency department.

On average, the emergency department saw around38,800 patients a year between 2013 and 2014, whichequated to around 746 patients a week.

The emergency department is a member of a regionaltrauma network. The hospital does not provide any otherhyper-acute services.

Urgentandemergencyservices

Urgent and emergency services


Summary of findingsThe emergency department at Hinchingbrooke Hospitalwas inadequate in respect of the safe and well-leddomains. We could not be assured that there weresufficient assurance processes in place to demonstratethat patients were not at high risk of harm when weinspected.There was minimal incident reporting andrecording within the emergency department. We couldnot see that completed incident reports had a clear‘lessons learnt’ approach. We looked at equipmentwhich was visibly clean, but found that some equipmentwas not maintained to the manufacturer’srecommendations with service labels highlighting that aservice was due. Medication was not securely storedappropriately, and daily checks on emergencyresuscitation trollies were not carried out by staff. Staffvacancies were covered with bank and agency staffwhich accounted for over a quarter of the staff numbers.Paediatric cover for children in this department was notsufficient to cover 24 hours, and staff did not have thecompetency to care for children when paediatric nurseswere not on duty. Since our visit the trust has employedpeadiatric agency and bank staff to cover 24 hours.

Clinical outcomes and monitoring of the service showedthat the trust was not outliers when compared to othershowever we found that the provision of care was notassured by the leadership, governance or culture inplace during our inspection. Patients were routinelytriaged within the waiting room area with noconsideration for their privacy or dignity. This practicewas not in line with departmental expectations; the trustdoes provide a private room suitable for triage andexpects staff to offer patients a choice. There was asenior member of nursing staff who was designated as ashift co-ordinator, and we found that the priorities andmanagement of the department were weak. When busy,two staff told inspectors that they accepted that theycould not give the care that they would wish to do so.We heard one patient request assistance and a memberof staff told them that they did not have time but wouldreturn. However after 30 minutes the patient stated thatno one had returned. We raised this issue to a memberof staff who assisted the patient.

The department was not responsive to the needs of allof the people who used it. Children had no seperatewaiting area and treatment rooms designed for childrenwere not always used for them. There were higher thanthe England average number of people who left thedepartment before being seen due to long waiting timesand those who were to be admitted also spentconsiderable lengths of time in the department. Theescalation protocol was not used effectively to reducepatients waiting times

Mental capacity assessments were being undertakenappropriately, and staff demonstrated knowledgearound most of the trust’s policy and procedures. Wesaw that staff were rushed with their workload, but tookthe time to listen to patients, and explain to them whatwas wrong and any treatment required. The staff wespoke with were proud to work in the emergencydepartment.




Are urgent and emergency services safe?


The emergency and urgent care services were judged asinadequate because safety systems, processes andstandard operating procedures were not fit for purpose.We found that there was significant bank and agency usewithin the department, equipment was not alwaysmaintained and medicines areas were not secure despiteCQC raising this as an issue. Staff were not utilising thesystem for reporting of incidents as this process too long,this meant that there was no improvements made to theservice as issues could not be analysed and trendsidentified. The ‘Stop the Line’ process designed forensuring senior management support to staff in caseswhere patient safety was a risk was not utilised by staff asthey saw it as ineffective. There were substantial andfrequent staff shortages. We found that children were notalways assessed by staff who had received training fortriaging them, and children shared the same emergencydepartment waiting area as adults, which was not in linewith ‘Children and Young People in Emergency CareSettings 2012’ standards. We were concerned that thedepartment had not used an acuity tool to determine thenumber of children’s nurses required to safely staff thedepartment. Since our inspection the trust has employedagency peadiatric nurses to support children's serviceswithin this department.

Staff were aware of the challenges within the departmentregarding service provision against demand, and wereworking towards addressing those challenges.

Incidents• The hospital reported one serious incident (SI) to both

the National Reporting and Learning System (NRLS) andthe Strategic Executive Information System (STEIS),relating to the accident and emergency departmentbetween 2013 and 2014.

• We asked staff directly if they reported incidents andhad knowledge of the reporting system. The incidentdata supplied to the CQC during inspection shows thatthe emergency care centre reported 256 incidents sinceApril 2013, accounting for only 4% of the total incidents

reported. Staff indicated that this low level of reportingreflected the amount of time it took to complete reportsand the limited feedback on outcomes or closure ofreported incidents.

• We spoke with senior nursing staff, who could notdemonstrate to us evidence of learning from incidents.Staff told us that the trusts 'Stop the Line' policy isineffective, and involvement by executive managementdid not always happen. (The trust employs an initiativecalled 'Stop the Line', which aims to empower anymember of staff to raise concerns regarding patientexperience or safety.)

• The department holds monthly clinical governancemeetings, with a regular agenda. Both clinical andnursing staff are invited to attend these meetings. Weattended a clinical governance meeting during ourinspection, and found no nursing staff present. Therewere doctors present representing senior, middle andjunior grades. We were told that feedback and actionsare then taken to a consultants meeting. We looked atprevious clinical governance meeting minutes andpathway tracked an action point whereby a fracture wasnot diagnosed. We then observed a consultant provideeducation to other doctors around this issue andsigning off the action point where required to reportback at the next meeting.

• The department displayed key safety related issues inthe public areas; However, This information did notinform people who use the services of anymeasurement, assessment, lessons learnt to improvethe safety of the care provided.

Cleanliness, infection control and hygiene• Evidence provided by the trust demonstrated a high

level of compliance with hand hygiene practices acrossa number of months, as observed during hand washingaudits, however we observed limited personalprotective equipment and hand hygiene practices in useduring our inspection. Not all staff were witnessed to bewearing gloves, or washing their hands between dealingwith patients.

• We observed during our inspection that patients whomay have an infection, or were awaiting confirmation ofany infection, were nursed within a side room on theacute assessment ward. During the period of ourobservations we did not see treatment rooms routinelycleaned between patients.




• We noted during our inspection that there were handcleaning stations within all treatment areas; however,some dispensers were empty, including the mainentrance for patients entering the emergencydepartment treatment area. We observed ambulancestaff remove dirty linen and clean ambulance stretcherswithin the same area that patients were handed over,and could not see a specific area identified for thisactivity.

Environment and equipment• Resuscitation equipment was available and clearly

identified. There was a specific children’s equipmenttrolley. Not all resuscitation trollies had been checkeddaily, and we noted on one trolley that daily checks hadbeen only been carried out during September 2014 on 2,5 and 11.

• Treatment cubicles were clean and well equipped withappropriate lighting.

• We looked at equipment which was visibly clean butfound that some equipment did not have maintenancelabels attached to it. The trust provided a schedule ofmaintenance and we could see that 94% of equipmenthad in fact been maintained. The trust stated that therehad been previous issues with labels being incorrectlyapplied to the lead of the equipment rather than themain body. The trust has reported that this practice hasnow been amended. Whilst this schedule showsequipment to be serviced the inspectors found that atleast 12 pieces of patient assessment equipment, suchas defibrillators and blood pressure monitoringequipment, did not have the date of the last PAT test orservicing and that some had stickers which stated whenthe last test was undertaken and some when the nexttest was due.

• The children and young people’s areas department wasnot fully compliant with standards for ‘Children andYoung People in Emergency Care Settings 2012’. We sawthat the children’s department was not dedicated onlyto children and young people. This meant that childrenwaited in the general A&E waiting area, were triaged inthe same system as adults, and were treated in areaswhere adults were seen. Staff raised concerns to us thatthis was not safe for children, but told us that thedepartment was planning a renovation inclusive of a

separate paediatric A&E department; however, neitherstaff nor documents could confirm when and how thiswas going to happen. We were therefore not assuredthat the environment was suitable for purpose.

Medicines• During our inspection, we checked the records and

stock of medication, including controlled drugs, andfound some discrepancies with regards to controlleddrug management as outlined below. Appropriate dailychecks were carried out by qualified staff permitted toperform this task.

• We found that the outer door of the cupboard housingthe locked controlled drug cupboard could be opened;the controlled drug cupboard and medicines remainedsecure but this potentially allowed access to thecontrolled drug book, which could enable tamperingwith the documentation confirming the issue ofcontrolled drugs. Therefore medicines wereinappropriately stored. We also found the drug fridgewithin the resuscitation area unlocked which containeda selection of muscle relaxants. We were told that therewas an ongoing investigation with regards to anampoule of diamorphine that could not be accountedfor. This had been formally reported and was beinginvestigated.

• We looked at patient prescription charts, which werecompleted and signed by the prescriber and by thenurse administering the medication.

• On a number of occasions during our inspection weobserved insecure drug cupboards, including an outerdoor on a controlled drug cupboard, and a storageroom containing intravenous fluids with the doorpropped open. We spoke with the nurse and a seniormanager around the associated risk of this practice, andrequested that it be addressed straight away, and wewere assured that this would be actioned. On thesecond day of our inspection we again found, onnumerous occasions, the intravenous fluid store dooropen and insecure.

• Fridges to store appropriate medication did not havethe temperature recorded and checked on a daily basis,and the fridge was not locked.

• The trust reported that they were awaiting delivery ofdigital locks and have replaced all locks with digital lockto ensure security of these areas. The trust states thatthese are now in place.




Records• We looked at 14 sets of patient notes during our

inspection. One of the sets of notes highlighted delays inthe recording of patient observations. One patientarrived in the department via ambulance and did nothave an initial recording of observations for 53 minutes.

• All of the notes we looked at had completedobservations taken, with regular re-assessment, whichwere recorded.

• During our inspection we observed that the emergencydepartment notes and acute assessment notes werestored securely. Notes were easily defined betweenclinical observations and nursing/medical notes.Documentation was of a high standard, with legiblenotes, and in line with best practice guidance. Childrenhad a thorough history recorded, as well as furtherassessments of their risks and needs, a diagnosis, and atreatment plan. The records reflected the holistic needsof each child.

• We saw, within the accident and emergency notes, thatrisk assessments were undertaken in the departmentwhen patients were in the department for some time (itis recommended by the Royal College of Nursing that ifpatients are in an area for longer than six hours a riskassessment for falls and pressure ulcers should becompleted).

• We observed that intentional rounds took place bynursing staff on the admissions unit but not within theaccident and emergency unit. This is where staff checkon patient’s welfare at regular periods throughout theday.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards• Staff were knowledgeable about how to support

patients who lacked capacity. They were aware of theneed to assess whether a patient had a temporary orpermanent loss of capacity, and how to supportpatients in each situation. If there were concernsregarding a patient’s capacity, the staff ensured that thepatient was safe and then undertook a mental capacityassessment.

• According to the emergency department mandatorytraining database, all nursing and medical staff hadundergone their mental capacity training.

• We observed nursing and medical staff gaining consentfrom patients prior to any care or procedure beingcarried out.

• There was a robust practice in place to support peoplewith drug and alcohol misuse, with referral to theappropriate supporting mechanisms available.

• Staff obtained patient and/or parental consentappropriately. The trust had appropriate policies inplace in relation to consent to treatment in children.Staff were knowledgeable about Gillick competence.These guidelines are tools used to assist professionals indetermining whether a child is mature enough to maketheir own decisions about care and treatment.

• The trust stated that one child had waited 19 hours tobe seen by the CAMHS in the department. The trustensured that the safety needs of the child had been metduring this time through appropriate escalation andactions taken. However the trust needs to work inpartnership with local partners to address children’smental health needs. CAMHS delays are a recognisedissue across the region, and this is discussed at thecombined safeguarding paediatric clinical governancemeetings.

• Records confirmed that at times the department wasseeing a high number of paediatric attendances with ahistory of self-harm. For example in 2013, 94 childrenattended the department with a history of self-harm,and in 2014 to date, there have been 13 attendances.

Safeguarding• The emergency department had a safeguarding lead

within the department who was knowledgeable, anddemonstrated underpinning knowledge of bothsafeguarding children and vulnerable adults.

• We looked at training records, and saw that all nursingand medical staff had undergone mandatorysafeguarding training at an appropriate level.

• All safeguarding concerns were raised through aninternal reporting system. The concerns were reviewedat a senior level to ensure that a referral had been madeto the local authorities’ safeguarding team.

• The staff we spoke with were aware of how to recognisesigns of abuse, and the reporting procedures in placewithin their respective areas.

• There was a team within the trust dedicated tochildren’s safeguarding. Staff gave examples of how theyand the safeguarding team had worked effectively withother children’s services, including the local authority, toactively safeguard children. Staff said that thesafeguarding team were highly visible and effective.




• Systems were in place to safeguard children, including ascreening tool used during initial assessment, whichidentified those children at high risk. There were auditsin place which demonstrated that this tool was notalways being used effectively; however, we saw that anaction plan was in place to support improvements. Thissystem had also been implemented in other areas of thehospital.

Mandatory training• We looked at mandatory training records, which showed

us that staff received core subject mandatory training,such as manual handling, fire safety, safeguarding, andbasic life support. However, we spoke with medical staffwho told us that they did not receive a comprehensiveinduction; for example, doctors received presentationswith regards to spinal immobilisation assessment, butthe practical assessment was not carried out.

• Mandatory training was provided in different formats,including face-to-face classroom training. Staff told usthat there was limited time allowed to completelearning. One member of staff told us that they rarely gotto see the staff that they should be mentoring andmeeting with, due to workload, and not being permitteda day to complete this, due to low staffing availability toback fill.

Management of deteriorating patients• There were appropriate systems in place to assess and

monitor patient risk. The emergency departmentoperates a national early warning score (NEWS), and thisis used to alert clinicians of any deterioration in apatient’s condition.

• The service had implemented a paediatric early warningscore (PEWS) system for varying ages of child. Earlywarning scores are generated by combining the scoresfrom a selection of routine patient observations, such aspulse, respiratory rate, respiratory distress andconscious level. Different observations are selected forchildren and adults due to their naturally differentphysiological responses. If a child's clinical condition isdeteriorating, the 'score' for the observations will(usually) increase, and so a higher or increasing scoregives an early indication that intervention may berequired. There were display boards visible to the publicwhich explained the PEWS system.

• We observed that the department operates a triagesystem of patients presenting to the department either

by themselves or via ambulance, and patients are seenin priority, dependent upon their condition. Childrenwere seen as part of this triage system and did not havea separate area for triage.

• Paediatric audits received from the trust show that 99%of children receive an assessment within the target of 15minutes. However during our inspection parents told usthat the service needs “a separate A&E for children”, andthat “the waiting time in this department [for children] isunacceptable”. During our inspection we observed thatone child waiting more than 15 minutes to be assessed;this was a very unwell child who required promptassessment. We immediately bought this to themanager’s attention, and appropriate action was taken.

• Patients arriving as a priority call are transferredimmediately through to the resuscitation area. Suchcalls are phoned through in advance (pre-alert), so thatan appropriate team are alerted and prepared for theirarrival.

• We looked at a pre-alert form with regards to a pre-alertthat occurred during our inspection, and found that theforms had been completed fully, with any clinicalobservations recorded, estimated time of arrival of theambulance to the accident and emergency department,and details of who took the information over thetelephone from the ambulance service.

Nursing staffing• Information provided by the trust indicated that the

establishment for the emergency department was notoperating at the required whole time equivalents (WTE),with a number of qualified nurse posts vacant. Seniorstaff acknowledged that they were looking at the RCN‘BEST’ policy to understand their staffing needs. Thecurrent vacancy percentage across the emergencydepartment at the trust is 26%.Bank and agency staffingwere used to support at times when there were knowngaps in the rota. The use fluctuated but was around 3%of total staff in the department.

• Staffing records confirmed that there was only onejunior paediatric nurse who worked full time to coverthe entire department. There was also a seniorpaediatric sister who worked full time; however, theirrole was supernumerary, although they told us that theirrole was adaptable, so they could work a clinical shift, asrequired. Staff told us that other registered nurses whowere not children’s nurse qualified, provided emergencycare to children when a paediatric nurse was not on




shift or available. These nurses had obtained additionaltraining, such as Advanced Paediatric Life Supportqualifications. However, the Royal College of Nursing(2013) guidance advices that there must be a minimumof one registered children’s nurse available at all timesin emergency departments. This meant that the servicewas not following national guidance in regard to safestaffing numbers.

• We found that a specific paediatric acuity tool had notbeen used to determine safe nurse staffing levels. Thismeant that the service had not planned theestablishment of the paediatric nurses it required toprovide safe care for children and young people. Seniormanagers told us that due to the increased number ofpaediatric attendances recently, paediatric staffing inA&E had been identified on the A&E risk register.

• Senior managers told us that the nurses who weretriaging at the front desk in A&E were not always trainedin paediatric assessments. This is not in accordancewith the national standards set out in ‘Children andYoung People in Emergency Care Settings 2012’, whichstates that nurses who are responsible for triagingchildren must undergo an assessment of competenciesin the anatomical, physiological and psychologicaldifferences of children. We were not assured that all staffassessing children were competent to deliver such care.

• We raised these concerns to the trust who took action intemporarily employing additional qualified paediatricnurses in the department. Since our inspection the trusthas employed paediatric agency nurses to ensure thatthe department has 24 hour cover with children’snurses. Adverts to recruit paediatric nurses are currentlybeing drafted.

• We observed that there was a professional handover ofcare between each shift.

• All bank and agency staff received local induction priorto starting their shift.

Medical staffing• The department currently has 14 whole time equivalent

(WTE) doctors, who are present in the department, withconsultant cover available from 8am until 9pm. Thereare middle grade doctors and junior doctors overnight,with an on-call consultant system.

• Within the emergency department, we saw that therewas a better ratio within the doctor staffing skill mixthan the England average. The emergency department

provided a whole time equivalent of 28% withinconsultant level (England average of 23%), 43% withinmiddle grade doctors (England average 39%), and 29%within junior grade level doctors (England average 25%).

• We looked at the doctor’s rota, and saw that the middlegrade doctor utilisation level was consistent in usingdoctors who had received the trust inductionprogramme, and were familiar with the department andprotocols.

• The emergency department currently has no clinicaldirector, and this was identified as a risk by thedepartment and senior managers. This has caused alimitation within the scope of practice and developmentof the department, with regards to leadership andinteraction with other directorates in the trust.

• During our observation within the clinical governancemeeting, we were told that junior doctors had notreceived a full induction into the emergencydepartment, as two days induction had beencondensed to one day, and elements of practicalscenarios, such as for cervical spinal immobilisation andmanagement, were delivered by presentation ratherthan with hands-on practice.

Major incident awareness and training• All major incident equipment was available and we saw

that it was checked on a regular basis• We requested evidence of training for major incidents

for all staff within the A&E department. We wereprovided with training data for nursing and medicalstaff. This demonstrated that staff had completed majorincident training and that 70% of nursing staff hadcompleted chemical, biological, radiological andnuclear training. We were also told that all staffcompleted major incident training, as part of theirinduction.

Are urgent and emergency serviceseffective?(for example, treatment is effective)

Not sufficient evidence to rate –––

We do not currently rate this aspect of the servicehowever we found that the department used a range ofpolicies, procedures and pathways which reflectednational guidance to ensure that patients received good




care and outcomes from treatment. However care plansand care pathways were not always followed by nursingand medical staff. Results of audits were not alwaysavailable for staff to learn and develop practice from.

Evidence-based care and treatment• Departmental policies were easily accessible, which staff

were aware of and reported they used. A range ofemergency department protocols were available, whichwere specific to the emergency department.

• There were further trust guidelines and policiesoperating within the emergency department and acuteassessment unit, such as sepsis and needle stick injuryprocedure. We saw treatment plans which were basedon the National Institute for Health and Care Excellence(NICE) guidelines.

• We found reference to the College of EmergencyMedicine (CEM) standards, and spoke with medical staffwho demonstrated knowledge of these standards.

• We looked at the process followed with regard toadmitting patients, and found that the acuteassessment unit (AAU) was not aligned to theemergency department processes. We saw that whenadmitting patients into the AAU, there were sixprocesses to record the admission. We asked why thesystem was not streamlined and were told that it was toovercompensate for information technology (IT) failure.

• We examined co-ordinated and integrated pathways forchildren’s services, which ensured collaborative workingbetween A&E and the children’s ward within the hospitalrun by another trust.

• Staff demonstrated that they practised evidence-basedcare. During our inspection we observed a paediatricburns patient and were assured that their care wasdelivered in line with current burns and scalds guidanceissued by the National Institute for Health and CareExcellence (NICE).

Nutrition and hydration• During our inspection we pathway-tracked a patients

care plan against the care they received. Entries into thecare plan were inconsistent and care pathways were notfollowed. For example, diabetic care was observed to bebelow what is expected. One care plan stated 'diabeticpatient, consider providing food'. We spoke with thispatient and were told that they had not received aregular meal and were provided biscuits at anunreasonable time.

• We observed that intentional rounding was taking placewithin the acute assessment unit; however, this focusedon observations being taken and we did not witness anychecks that food or drink were offered. During ourinspection we did not see any intentional roundingtaking place within the emergency department.

• We observed catering staff within the AAU offeringbreakfast to patients who had been in the unitovernight.

• We found that fluid charts had not been fully completed,with observation times missing.

• We found that children’s nutrition and hydration needswere not always met.

Patient outcomes• The emergency department took part in national

College of Emergency Medicine audits, and they wereable to provide us with the results of these,but therewas no evidence that they had used the results to assessthe effectiveness of their department.

• The College of Emergency Medicine recommends thatthe unplanned re-admittance rate within seven days foraccident and emergency should be between 1-5%. Thenational average for England is around 7%. The trusthas consistently performed well against unplannedre-admittance since January 2013. Their rate in February2014 was just below 6%.

• At local level, a number of audits within the children’sA&E services had been conducted. This includeddocumentation audits which demonstrated goodcompliance with national standards. During August2014, the documentation audit revealed that 100% ofnotes reviewed included the child’s name, school andinvestigations undertaken. Other audits included theuse of the safeguarding tool. This meant that the trustwas actively monitoring the quality of its service.

Competent staff• Appraisals of both medical and nursing grades were

undertaken, and staff spoke positively about theprocess and said that it was of benefit. The trust iscurrently going through a change within their appraisalsystem and process; therefore figures are not reliable atthe time of our inspection.

• We saw records which demonstrated that both medicaland nursing staff were revalidated in basic, intermediateand advanced life support.




Multidisciplinary working• Medical and nursing handovers were undertaken

separately, during the nursing handovers whichoccurred twice a day, staffing for the shift was discussed,as well as any high risk patients or potential issues.Medical handover occurred twice a day, and was led bythe consultant on the A&E floor.

• There was a clear professional conjoined workingrelationship between the emergency department andother allied healthcare professionals within otherdepartments and hospitals. For example, the mentalhealth teams provide intervention from communityservices to enable patients to be discharged home withan appropriate care package and support from otherhospitals.

• Staff we spoke with were aware of the protocols tofollow, and key contacts with external teams. Wewitnessed a professional patient experience, fromtransition from the care of the ambulance service to theaccident and emergency staff.

Seven-day services• There was a consultant out-of-hours service provided

via an on-call system.• Accident and emergency offered all services, where

required, seven days a week.• We were told by senior staff within the A&E department

that external support services are limited out of hours,and it often proves difficult at weekends, which has aneffect on patient discharges and care packages.

Are urgent and emergency servicescaring?

Requires improvement –––

There were times when people did not feel wellsupported and cared for therefore we have judged caringas requiring improvement. Some people told us that theywere concerned about the ways staff treated them. Wereceived 17 comment cards from this department. Twelvecomments indicated that patients were not alwaystreated with respect and in one stated that they were notbelieved when receiving treatment; however, Friends andFamily feedback and the national A&E patient survey

commissioned by the CQC contradicts this finding. Staff inthe department focused on the task in hand rather thanensuring that patients had information about their careand treatment.

We saw patients getting frustrated that they were waitingextended periods for treatment and lack of information;however staff reported that they wished they had moretime to care. The department has worked hard toincrease the Friends and Family Test response rate;during our inspection we did find Friends and Family Testquestionnaires in view, and available within theambulance triage and reception areas.

Compassionate care• We saw that nursing staff were busy, and this was

demonstrated in the lack of time that each nurse wasable to spend with an individual patient for whom theywere providing care. We spoke with staff and they toldus that they were frustrated that they could not providesufficient time at the patient’s bedside to understandeach patient’s full needs.

• The trust performs better than the England average forthe NHS Friends and Family Test (the Test wasintroduced in 2013 and asks patients whether theywould recommend hospital wards, A&E departmentsand maternity services to their friends and family if theyneeded similar care or treatment). The trustsperformance is better than the average for the accidentand emergency department.

• During our inspection we saw three occasions wherebypatients had to wait a considerable amount of timewhen they called for a nurse via a call bell in the cubicle,and when the nurse arrived there was very littlecompassion shown. For example, we saw that a nursespoke abruptly to the patient and was rushed inspending time with the patient and told the patient thatthey were very busy. We informed a hospital managerabout this.

• Out of 17 comment cards completed by patients duringour inspection 16 contained negative comments. Wesaw some significant concerns about the lack ofcompassionate care. One patient felt that theircondition was not taken seriously despite later findingout that they were suffering with a serious condition.We informed the director of nursing about some ofthese comments.

• The national A&E patient survey commissioned by theCQC, which had a trust response rate of 35% compared




with a national response rate of 34% and that wasresponded to by 293 patients who had used the trust'semergency department services, contradicts ourcomment card findings, with patients scoring the trustat 9/10 for patients feeling they were treated with dignityand respect, an increase from 8.5/10 in 2012.

Patient understanding and involvement• Patients told us that they did not always feel informed

about the care they were receiving, and had to asknurses and doctors to update them, rather than staffkeeping patients informed. The patients we spoke withtold us that staff were polite when speaking to them.During our inspection there were delays during the dayfor patients waiting to see a doctor. We did not observestaff explaining to patients if there was going to be adelay in seeing a doctor, what the reason for that delaywas, and how long they would have to wait to be seen.

• One person in the waiting room told us “there are toolong waiting times and the screen to tell peopleinformation is out of view and I can’t see it from thewaiting area”. Another person told us that they had notheard their name being called, and when they broughtthis to the attention of the triage nurse they were toldthat they would just have to wait, without being askedwhat was wrong.

• We received a number of concerns in respect of the careof diabetic patients within the department. Peopleattending the listening events prior to the site visit toldus that despite asking for food and/or insulin stafflacked an appreciation of their need for these to controltheir blood sugar.

• The department arranged the nursing staff into teamsthat looked after specific areas; this did not alwaysfacilitate a better patient experience. For example, onenurse we spoke to told us that when the department isunderstaffed, patients may wait for a longer period, asnurses are not moved around, and remain working inthe one area.

Emotional support• We spoke with staff about their understanding of

bereavement services offered within the emergencydepartment, and we were told that staff call upon thechaplaincy service.

• During our inspection we spoke with staff, includingreception staff, and asked what training they hadreceived to deal with distressed people that attend theemergency department; we were told that no trainingwas provided to initially support these people.

• There was limited information available to supportpeople during a time of bereavement, and also takinginto account religious and cultural needs.

Are urgent and emergency servicesresponsive to people’s needs?(for example, to feedback?)


Services do not always meet the needs of patientstherefore we have judged the responsiveness of theservice as requiring improvement. There were shortfallsin the services for children in terms of the waiting roomand the treatment areas which were not exclusively usedfor children despite being decorated for them. There werea higher than the England average number of people wholeft the department before being seen and those whowere due to be admitted waited long periods of timebefore being taken to a ward. It was unclear as to theactions taken by the department to address this.

The department struggled with surges of activity, whichoccur on a regular and potentially anticipatory basis. Theescalation protocol is insufficient, and does not provide asufficient or measurable safe response, as evidenced bypatients waiting above fifteen minutes within theambulance triage area whilst ambulances are waiting tohandover. However the hospital was generally meetingthe national four hour target to see and treat patients.

Service planning and delivery to meet the needs oflocal people• We were told by senior staff within the department of

who, within the site team, should be contacted whenthere were delays to patient flow. There was an internal‘live’ electronic system of monitoring to evaluate andmanage the effectiveness of patient flow to assist withbed demand.

• During periods of demand, the department started tostruggle; there was a lack of co-ordination within teams,resulting in a failure to achieve a better patient




experience and flow through the department. Forexample, we witnessed nursing tasks that were overdueto be completed and no ownership of patient centredcare with staff not knowing the condition of patientsunder their care when there was a telephone enquiry.We also saw patients waiting to be transferred out of thedepartment and when we spoke to a senior nurse aboutthe cause of this we were told that it’s like this all thetime and they shrugged their shoulders.

Access and flow• On average, the trust maintains the 95% target of

assessment of people within four hours of arriving in theemergency department. There have been sevenoccasions of breaching the 95% target between April2013 and April 2014. Prior to the week of our inspection,the trust achieved 86.5% of patients seen within 4 hours..

• The trusts percentage of emergency admissions via theemergency department, waiting 4-12 hours from thedecision to admit until being admitted, have beenconsistently worse than the expected England averageof 5%. The trusts emergency department had anaverage of 20% of patients waiting 4-12 hours from thedecision to admit to being admitted.

• The national average for percentage of patients thatleave the department before being seen (recognised bythe Department of Health as potentially being anindicator that patients are dissatisfied with the length oftime they are having to wait) was 26% (July 2013 – July2014). The England average was 16%.

• Patients, parents, staff and our observations confirmedthat patient flow throughout the service was not alwaysseamless, because there was not a separate pathway forchildren and young people.

Meeting people’s individual needs• Staff we spoke with were unaware of the translation

service available for those patients whose first languagewas not English. Within the department we were told bystaff that it was not possible to request a translator. Thestaff we spoke with told us that they would usually useother staff members to translate.

• There were no information leaflets available for manydifferent minor injuries. Those that were provided wereavailable in English.

Learning from complaints and concerns• The A&E department advocates the Patient Advice and

Liaison Service (PALS), which is available throughout thehospital.

• Information was available for patients to access on howto make a complaint, and how to contact the PatientAdvice and Liaison Service.

• All concerns raised were investigated, and there was acentralised recording tool in place to identify any trendsemerging.

• We did see that learning from complaints was within theagenda of the clinical governance meeting, and wasdiscussed amongst the doctor peer group; however, thiswas not disseminated to the whole team in order toimprove patient experience within the department.

Are urgent and emergency serviceswell-led?


During the period of our inspection, we were not assuredthat governance procedures that would maximise theopportunity to identify, report and learn from incidents toimprove services were followed in the emergencydepartment. The department has a lower than expectedrate of incident reporting, at 4% of the trust's overall rate.Staff reported that this was reflective of the time it takesto complete reports coupled with lack of feedback fromthe incidents reported. The trust stated that they hadrecognised this and invested in web-based incidentreporting and risk management software to reduceadministrative burden on frontline staff and facilitateimproved triangulation and learning from incidents.Patient outcomes data and the CQC's own national A&Epatient survey confirm that the trust is not a negativeoutlier in respect of harms or patient experience. Thetrust's performance in July 2014 fell to 92.9%; its firstmonthly drop below a 95% achievement. Year to datefigure was 95.2%, which compares favourably with otherNHS trusts and is not indicative of a poorly managedservice.

The trust were clear about the vision and values, andproduced may leaflets on these, that they and its staffsubscribed to however there was a lack of awareness oftheses within the department. Governance procedures




were not being followed in respect of reporting incidents,and improving services in response to these. Whilst riskwere identified and audits undertaken there was littleevidence that these were addressed or used to improveservices.

The front line leadership was not robust enough to flex tothe needs of the department. We saw that theorganisation of staff to manage the department wasineffective at times of increased demand. There was poorcollaboration between teams during these times whichimpacted on the safety, caring, effective andresponsiveness of the service. Universally throughout thedepartment, there was an acceptance of a lower standardof care due to pressure, but staff were concerned by thedeparture of numerous senior managers within theemergency department. The staff we spoke withdemonstrated an attitude of commitment, but moralewas low.

Vision and strategy for this service• The future vision of the accident and emergency

department was not embedded within the team, andwas not well described by all members of staff we spoketo including managers. This included the developmentof the A&E department and its growth plans in buildingsize and development of children’s services it may offer .

• The children and young people’s service within A&E didnot have a clear vision and strategy with identifiableaims and objectives. Whilst staff told us that there weretrust plans to renovate and separate children’s A&E,records did not support this happening in a timely way.We could not be provided with any dates or businessplans for completion of this work when we spoke with asenior manager. Staff also told us that “these plans havebeen on the cards for years but nothing happens”.

Governance, risk management and qualitymeasurement• Monthly departmental meetings are held. We were

provided with minutes of the previous meetings held.There was a set agenda for each of these meetings, withcertain standing items.

• Within the minutes, the top risks were discussed, Theredid not seem to be any embedded concern around themanagement of the risk register including currentupdates or any regular review within an accepted timeframe.

• A live information dashboard was displayed within theemergency department and acute assessment unit atHinchingbrooke Hospital for the public to see; we spokewith staff about quality indicators and there was a lackof demonstrable knowledge.

• The trust held three monthly children’s clinicalgovernance meetings in partnership withCambridgeshire Community Services NHS Trust. Staffsaid that this was an opportunity to learn and discusscomplex cases and incidents. We were concerned thatthese meetings were not occurring frequently enough.This meant that there could be missed opportunities inrelation to improving and learning from practice. Wewere also concerned that the most senior personattending from children’s services at HinchingbrookeHealth Care NHS Trust was the lead nurse forsafeguarding and/or the senior paediatric nurse fromA&E. This meant that there was an absence of seniormanagement at the clinical governance meetings.

Leadership of service• There was an evidential departmental team, which was

respected and led by the divisional head of nursing foremergency and urgent care.

• The senior management team were interviewedseparately, and the conclusions drawn from theinterviews were that the leaders visions were notaligned, and at the time of the inspection there was alack of joint ownership of the issues faced by thedepartment. For example, a number of key leaders haveleft the department, including the emergencydepartment matron. A decision was made to have onematron looking after both the acute assessment unitand the emergency department.

• During our inspection, we observed that there was adisengagement of leadership from the emergencydepartment matron, with regards to the priorities andmanagement of their department. This disengagementimpacted upon the effectiveness and responsiveness ofthe department.

• The senior paediatric nurse of A&E was dedicated,enthusiastic and inspiring. They demonstrated clearleadership principles and the trust’s values. Staff spokehighly of their seniors. They said that they felt respected,valued and incredibly supported by the seniorpaediatric nurse.

• Staff we spoke to in other departments told us that themost senior professional, with regard to paediatrics at




Hinchingbrooke Hospital, was the senior paediatricnurse in A&E. The paediatric nurse was evidently takingthe lead and influencing many positive, trust-widepaediatric decisions. However, they were not supportedappropriately, as there were no senior managers, inrelation to paediatric service provision, above them.This lead nurse reported directly to the divisional heador director of nursing.

Culture within the service• The high percentage of consultants within the

emergency department contributed to the cohesiveworking within the medical staff. There was an executivedirector for the emergency department and medicalservices but staff felt that the lack of an identified seniorleader for this service had the potential to impact on theculture within the service working with otherdirectorates in the trust and external stakeholders.

• We spoke with nursing staff, and universally, throughoutthe department, there was an acceptance of changeand aspirations to improve. Staff believed that withdepartmental improvements and redesign, a betterworking environment would be created in which to carefor patients and raise morale.

• Staff told us that the trust has policies and proceduresin place to protect both patients and staff, but they arenot effective. For example, one member of staff told usthat the trust has a 'Stop the Line' procedure, and whenthey try to use it they are made to feel that they are toblame, and that they have done something wrong wheninstigating 'Stop the Line'. Another member of staff toldus that they were told to “just get on with it” when usingthe 'Stop the Line' procedure. (‘Stop the line’ procedureis a policy that is in place throughout the trust wherebyany staff member who may witness an unsafe practicebeing carried out or concerns around health and safety

can instigate and invoke the ‘stop the line’ policy. Thereis a senior executive on call each day who will attendand deal with any issue as appropriate within trustpolicy and procedure)

Public and staff engagement• The emergency department scored consistently better

than the England average in the Friends and Family Test.• The trust confirmed that feedback was given to staff in a

number of ways, however the staff we spoke to told usthat they do not get department feedback from staffsurveys.

• We asked if the A&E department engages with membersof the public within a forum and were told that there isno forum for this other than completing a feedback cardand handing it in to the trust.

Innovation, improvement and sustainability.• Information for all staff about the trust’s vision and

strategy was available but staff were not aware how toaccess it. Staff told us that they were not aware ofupdates or amendments on the department’s prioritiesand performance

• The lead paediatric nurse in A&E had developed aninnovative new scheme, which was designed to engageyoung children from the local community with thehospital. Children from local primary schools are takenon a tour of the hospital, and get the chance toexperience some hands-on activities with regard to howthe hospital works, and gain insight into the varying jobroles. This scheme had been effective, and had alsobeen rolled out to include children and adults livingwith learning disabilities. The nurse had been awardedan Executive Board Certificate of Recognition for heroutstanding work in this area.




Safe Inadequate –––

Effective Requires improvement –––

Caring Inadequate –––

Responsive Requires improvement –––

Well-led Inadequate –––

Overall Inadequate –––

Information about the serviceThe medical care services at Hinchingbrooke HospitalComprise of five areas. Cherry Tree ward is a 30 bed wardcaring for elderly patients with acute medical conditions.There is also a focus on dementia care, within adementia-friendly environment. Walnut Ward takespatients with acute medical conditions, but has a specialistinterest in respiratory conditions. Apple Tree Ward has 25beds, and focuses on rehabilitation after treatment ofacute illnesses, such as stroke. The Medical Short Stay Unitis a 30 bed ward that cares for patients with a range ofmedical conditions, for up to three days. The ward alsoprovides a short stay service for gynaecological conditions.The Reablement Centre is a 25-bedded non-acute unit. Itprovides care for patients with confirmation of theirmedical fitness for discharge. Patients admitted to the warddo not necessarily require rehabilitation and are a mix ofpatients requiring long term residential nursing careprovision in the community, as well as those returning toindependent living arrangements.

Monitoring had not indicated any increased risk in respectof pressure ulcer, urinary tract infections of falls with harm.The Trust has a low incidence of hospital acquired pressureulcers and falls with harm. We had been notified bystakeholders prior to this inspection that there wereconcerns around infection control practices, andcleanliness in the medical areas.

We visited all of the medical areas as part of this inspectionover two days. We returned to visit Apple Tree Ward on

both unannounced visits. We examined 15 sets of patientrecords; spoke with 23 patients, 10 relatives or carers, and28 members of staff, including doctors, nurses and supportstaff.

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Medical care (including older people’s care)


Summary of findingsMedical services were inadequate because we foundpoor emotional and physical care which was not safe orcaring. This was not reported by leaders of the service tothe trust management therefore we judged theleadership to be inadequate. Services were not caringbecause people were not treated with dignity orrespect. We were also concerned that people were notbeing treated in an emotionally supportive manner.Hand hygiene and infection control techniques werepoor. Staffing numbers were not always reflective ofpatient dependency. Examples of treatment withoutconsent were identified on one patient who lackedmental capacity but we found an under recognition ofpatients who may lack capacity throughout the medicalwards. Services were not effective because pressureulcer prevention and treatment was not alwaysprovided in line with NICE guidelines. There were noseven day services provided by the hospital. The servicewas not responsive; we found that medical patientswere not always classed as outliers despite requiringspecialised care. This meant that the frequency ofreview by their own consultant might be reduced. TheMedical Short Stay Unit and the Reablement Centrewere not utilised for their intended purpose.

The service was not well-led. We found that the cultureof identifying, reporting and escalating concerns wasnot open. We found that teams were not engaged or feltenabled to raise concerns. We wrote to the trust toexpress our concerns and with the support of the TrustDevelopment Authority action underway to addressthese.

Are medical care services safe?


Patient's using the medical services were at risk fromavoidable harm or abuse in Apple Tree ward. Staffthroughout the service were not always adhering to theNational Institute for Health and Care Excellence (NICE)Guideline CG:179 ‘Pressure ulcers: prevention andmanagement of pressure ulcers’, because we found littleevidence that preventative measures were consistentlybeing implemented. Care plans for monitoring of cannulasites and catheters were not always being completed.Infection control protocols were not being adhered to. Weobserved poor hand-washing technique between patients,and poor practice of hand hygiene by medical and nursingstaff between patients.

Where patients had the mental capacity to consent totreatment, consent was taken. Where patients did not havethe capacity to consent, best interest procedures inaccordance with the Mental Capacity Act (MCA) and theDeprivation of Liberty Safeguards (DoLS) were not alwaysundertaken prior to treatment being given.

Whilst the staffing number had been met, the quality andcompetence of these staff members varied; we noted thatmany of the concerns that we raised to the seniormanagement team related to the bank and agency staffmembers on duty. Nurse staff levels are calculated basedon patient to staff ratio. This model of staffing was notreflective of patient needs, and wards were not able tocomplete basic nursing tasks due to patient dependencyoutweighing the staffing numbers.

Incidents• Staff were able to provide us with examples of when

they had reported incidents, and understood whatconstituted an incident.

• We spoke with a range of staff across the service, andfound that staff were aware of how to report incidents.However nurse on one of the wards told us “we arealways told to do incident forms, but who has the timeand nothing changes, therefore we don’t do them”. Ajunior doctor (CT1) on another ward told us that theyhad had to report an incident the day before ourinspection. This doctor told us that they had to get a

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nurse to report the incident because they didn’t knowhow to do it. The doctor did not know the process forreporting incidents, or how the outcomes of incidentsreported were fed back.

• In the 12 months preceding the inspection there hadbeen two unexpected deaths and 14 serious incidentsreported from the medical care services, including olderpeople's care. Of the serious incidents, five involvedpressure ulcers that had been acquired whilst under thecare of the trust, four involved patient falls, and one wasdue to serious infection.

• Lessons were learnt from incidents, we observedinformation on notice boards and on the monitorscreens displayed in the wards detailing what incidentsor concerns had been reported and what action thetrust had taken to make improvement.

• Mortality and morbidity was monitored by the clinicalleads for the service. The Staff discussed mortality atward meetings with the meetings being led by the leadconsultant. Mortality levels were within the expectedrange for the size of the hospital.

Safety thermometer• Pressure ulcers prevalence in medical areas has been

consistently high in the period between May 2013 andMay 2014, with 85 reported pressure ulcers at grade 2, 3or 4, however the trust states that 53 patients had beenadmitted to the wards with pressure sores from thecommunity. We reviewed three serious incidentinvestigations in relation to pressure ulcers, and foundthat they were completed through with lessons learntidentified.

• The medical care service has reported 44catheter-associated urinary tract infections (UTI’s)between May 2013 and May 2014. This is higher than theEngland average.

• We examined the records of six patients who hadcatheters in situ on Apple and Cherry Tree Wards. Wefound the recording of catheter care to be poor. Staffinformed us that they were required to check onpatients' catheters during their ‘care around the clock’on each shift; however, they could not demonstrate orassure us that they undertook those checks. Twopatients with catheters we spoke to on Cherry Tree Wardraised concerns to us that their catheters were causing

them discomfort, and staff had not returned to check onthem. We raised this with the senior sister on CherryTree Ward, who assured us that they would address thepatient catheter concerns.

• The service had a lower than England average numberof patient falls resulting in harm to the patient. Weobserved that where patients were identified as highrisk of falls, additional staff were booked to observe thepatients, to minimise the risk of falls.

• We examined the cannula site recording and cannulasites of patients who had cannulas in situ. This is ameasure on monitoring site infection risks. On AppleTree Ward we observed that three people with cannulashad their sites bandaged, and therefore the cannula sitewas not visible. Two patients we spoke with informed usthat their cannula was causing them discomfort. Allthree patients did not have a completed cannula caremanagement plan in place. It is best practice to havethese plans in accordance with the ‘Department ofHealth (2007) Saving Lives: reducing infection, deliveringclean and safe care. High Impact Intervention no 2,Peripheral intravenous cannula care bundle’.

Pressure ulcer care• During examination of 15 sets of records across all

medical areas, we found that only four pressure ulcerassessments had been completed correctly. We alsofound that in five cases where pressure-relievingequipment was required, this had not been provided tothe patients. Therefore, we were not assured thatlessons learnt from pressure ulcer investigations wereembedded, or that practices were improving.

• On Apple Tree Ward we observed one patient who wasat risk of their skin breaking down. Their pressure ulcerassessment had been incorrectly calculated because akey medication had not been considered. We also foundthat they were not on pressure-relieving equipment,including an air mattress, as required by the outcome oftheir assessment.

• A second patient on Apple Tree Ward had skin that hadbroken on their legs, for which they were receivingregular treatment in the community. This person’sassessment had also been incorrectly calculated andappropriate equipment had not been provided. Whenescalated to the matron, the person was re-assessed.However, during the unannounced inspection, wereturned and found that the patient had sores whichwere grade 2 on their leg, which had not been assessed

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or treated. A swab for infection had been undertaken on16 September, but the result had not been received orchased by the team six days later. This meant that therewas a potential delay in treating any infection that mayhave been present.

• We found that some staff were not classifying the grade,size or type of pressure ulcer, as defined by the‘European Pressure Ulcer Advisory Panel' (EPUAP). Inthree sets of notes that we reviewed, we found that staffhad not classified the grade, size or type of pressureulcer. There were no defining factors on the wound type,size, depth, colour, temperature, or if the area wasblanchable or non-blanchable.

• We examined the training matrix for the trust, and foundthat staff were provided with training on tissue viability.However, evidence found throughout the inspectionchallenges how robust the training methods provided tostaff are, as they have been unable to demonstratecompetency around tissue viability in all medical wardareas.

• Patients who were identified as being at risk of pressureulcer development, and required support withrepositioning, should have been supported to do thisduring the ‘care around the clock’ rounds. We foundinconsistencies in the recording of the turns andrepositioning of patients. We spoke with two membersof staff about this on Cherry Tree Ward, who informed usthat they were unsure whether the previous shift hadrepositioned patients.

Cleanliness, infection control and hygiene• Visual observations of the ward areas showed that they

were clean, and cleaning was being regularlyundertaken.

• We examined clinical equipment, including fourcommodes, two mattresses and resuscitation trolleysacross the wards, and found them to be cleaned to agood standard.

• The medical area had had a recent increase in thenumber of reported C. difficile cases. We were aware ofconcerns from stakeholders prior to our inspectionregarding the infection control practices within themedical care service. We observed care between staffand patients, and found that care was not beingprovided in accordance with the trust’s own infectioncontrol policy.

• There had been no MRSA infections reported in theprevious 12 month period.

• On Cherry Tree Ward we observed staff on threeoccasions come away from a patient, write in thepatient notes, then remove their apron, and then washtheir hands. This meant that the notes had beencross-contaminated.

• On Cherry Tree Ward we observed a consultant doctorexit a side room, where a patient was being treated forC. difficile, write in their notes on the notes trolley, thenremove their apron and use alcohol gel prior to going toanother patient. The consultant did not wash theirhands with soap and water, which is the most effectivemethod of controlling the spread of C. difficile betweenpatients.

• On Apple Tree Ward and on Walnut Ward we observedstaff walking around the bays to care for patients, thenexiting the bays whilst still wearing gloves and apronswhen this was not required. On Walnut Ward weobserved nurses wash their hands before removing theiraprons; in one instance we observed a bank nurse washtheir hands in the patient toilet area, then remove theirapron and leave the bay. We raised our concerns to thesenior sisters in charge of each ward.

• On Apple Tree Ward we intervened to prevent a finalyear student nurse from preparing an injection afterundertaking a patient intervention, without washingtheir hands in between.

• We saw that patients were not given the opportunity toclean their hands prior to eating their food.

• We observed that a majority of staff adhered to the 'barebelow the elbows' protocol defined in the trust’spolicies. However, we observed two staff memberswearing watches and three female staff members withjewellery on their hands that contained jewels. Thesemembers of staff were providing care to patients whenthe jewellery was identified.

Environment and equipment• Equipment was cleaned regularly, on Walnut, Apple

Tree, Medical Short Stay and the reablement wards wevisited.

• Resuscitation trolleys and equipment were checked,and records were kept.

• All sharps bins were dated, signed, and were notoverfull.

• We observed that some patients had bed rails in situacross all wards visited. Some bed rails were older styleand clipped on to the side of the bed. These bed railshad larger gaps between the rails and risked

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entrapment. We examined eight bed rail riskassessments for patients who had the older style bedrails in place. We found that the assessment did notdetermine what the appropriate bed rail type for thepatient was. On Apple Tree Ward we observed onepatient with their arm and leg through the bed rails.Therefore, the use of bed rails was not always safebecause the assessment for use did not cover allassociated risks of bed rail use

Medicines• We found that the storage and monitoring of medicines

was appropriate. Fridge and room temperatures werebeing regularly recorded. All items stored matched intally to those recorded as given from the records. Thecontrolled drugs were checked and all accounted for.

• On Cherry Tree Ward we identified one medication error,where a patient had been prescribed both regular andad hoc paracetamol. We identified that this person hadbeen administered over the recommended dosage of 4gper day. We raised this with the person in charge, andwith the lead consultant. We saw positive action takenby both to report the incident, to inform the patient andtheir family, and to undertake tests to ensure that noharm came to the patient.

• On Apple Tree Ward we identified three patients whohad not received their medicines on time. One patientwas to receive antibiotics for an infection. Theantibiotics had been missed from the medicine roundson more than two occasions. We examined themedication chart, which confirmed what we had beentold by the relatives of this patient.

• On Apple Tree Ward area we found that the medicinesfridge was being monitored on a daily basis, but hadbeen out of range since July, and no action had beentaken by staff to report it or resolve it. Medicines withinthe fridge on this ward were not being managedappropriately, and patients were at risk of receivingmedicines that could have been compromised. Weescalated this concern immediately to the ward matron.

• On Apple Tree Ward area we found that the medicinetrolleys used to transport medicines to patients wereoverstocked, and were kept in an unhygienic manner.Dust and debris was visible, both on the inside and onthe outside of the medicines trolley. One of the trolleyshad three bags of a patient’s own medication beingstored in it.

• All the medicines we looked at were within their expirydate. We saw that staff were dating and signing bottlesof liquid preparations, such as antibiotic syrup and eyedrops, at the time of opening. However, on all of themedical wards we inspected we found that staff werenot dating and signing the bottles of oramorph onopening. On Walnut Ward we found that insulin had notbeen dated and signed on opening. These preparationsshould be used within a specified number of days onceopened. These medicines were not managedappropriately, and patients were at risk of receivingmedicines that had expired.

Records• All records were in paper format. Nursing notes were

generally kept on the wall outside the patient bay,observation charts were retained at the end of patients’beds, and medical notes were stored in trolleys on theward areas.

• Healthcare professionals completed the records, andgood examples of multidisciplinary entries were seen inthe records to guide other professionals.

• The quality of conversations being recorded withpatients, together with visiting professionals advice,including dietician, and speech and language therapyservices, was good.

• The quality and consistency of the medical staff noteswas variable, with some doctors writing being illegibleto read.

• Admission checklists and patient safety checks were notconsistently completed, and risks around falls, venousthromboembolisms, and moving and handling, werevaried, with some noticeable gaps in recording. This wasespecially evident on Apple Tree and Cherry Tree wards

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards• Patients were consented appropriately and correctly,

where people were able to give their consent to careand treatment.

• We examined the training matrix provided by the trust,which showed that the training requirement in consent,the Mental Capacity Act (MCA) and Deprivation of LibertySafeguards (DoLS) was not routinely monitored as amandatory subject. We spoke with staff who confirmedthat they had completed training in MCA and DoLSonline through an e-learning module.

• We identified one patient who had been referred forreview by the adult safeguarding lead, due to

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challenging behaviour and the need for additionalsupport. On the first day of our inspection we found thatthey were in bed and asleep or quiet for a majority ofour visit, which was a contradiction to the entries in thenotes and information from the family regarding thisperson’s behaviour. We identified, through examiningtheir records, that they had been given a sedativemedicine. There was no best interest assessment ormental capacity assessment referred to in the records,prior or post administration of this medicine, despitethe patient lacking the mental capacity to consent toreceive this medicine. A referral to the DoLS team doesnot sufficiently cover the requirements of the MentalCapacity Act or Deprivation of Liberty Safeguards. Thetrust state that the capacity assessment was undertakenand the relatives spoken with on the phone but that thedoctor did not document this in the notes. Followingour inspection the trust commissioned an independentaudit of this case that concluded that the medicationgiven was appropriate but documentation ofassessments did not refer to either best interest ormental capacity assessment.

• We identified, through examination of 15 sets of medicalnotes on Cherry Tree Ward, Apple Tree Ward and in theReablement Centre, that there was anunder-recognition of delirium. Therefore, no clearinterventions were identified, and this placed patientsat risk of inappropriate treatment when they do nothave capacity. We established, through speaking withstaff and examining the training records, that staff hadnot received any awareness training on delirium.

Safeguarding• There was a lead nurse for safeguarding. However, when

we spoke with staff, only some senior staff knew of thesafeguarding lead. Most staff we spoke with were notaware of their presence.

• On Apple Tree Ward, during our observations weobserved an agency nurse enter a patient's bay whilstthey were asleep. The curtain was drawn and nointroductions or consent were heard to be given orreceived. The staff member then proceeded to wash thepatient with little interaction. We heard the patient say'ouch you are hurting me'. We reported our concerns tothe matron in charge to ensure that appropriate actionwas taken immediately.

• During the inspection, two members of the inspectionteam observed two different members of staff move

people in an unsafe manner. The manoeuvre used isknown as a drag lift. A drag lift is when the carer/personpulls a patient up by pulling/dragging them under theirarms. In once instance this manoeuvre whilst not liftingthe patient was used to reposition the patient. This cancause shoulder and spinal pain in the patient and carerand is classed as abuse by Age UK.

• We were not satisfied that safeguarding concerns werealways identified, or safeguarding alerts made whenthey should have been. Throughout our inspection wesaw staff speaking to patients in an abrupt manner, andwe saw unsafe moving and handling practices werebeing undertaken in Apple Tree ward that we inspected.

• Since our visit the trust has requested an independentreview of safeguarding from another trust. This visitfound that whilst the decisions made aroundsafeguarding and mental capacity had been correct thedocumentation of these decisions was poor. The trusthave altered the job role of the safeguarding lead andintroduced new systems to highlight to management ona daily basis those patients who may be vulnerable

Mandatory training• Mandatory training for the service is classed as fire

safety, infection control, moving and handling,information governance, Safeguarding Adult’s level 1,Safeguarding Children level 1, and equality anddiversity. In acute medicinearound 79% of staff hadreceived training. Within care of the elderly services 68%of staff had received mandatory training.

• Locally, staff informed us that they had online access toother training courses, including health and safety andtraining on the Mental Capacity Act. Records ofattendance for this training was not routinelymonitored, and we found the uptake of this traininglocally was sporadic.

Management of deteriorating patients• The medical wards used a recognised national early

warning tool called NEWS. There were clear directionsfor escalation printed on the reverse of the observationcharts, and staff spoken to were aware of theappropriate action to be taken if patients scored higherthan expected, and may need intervention.

• We looked at completed charts and saw that staff hadescalated patients’ conditions correctly, and in most

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cases, repeat observations were taken within thenecessary timeframes. There were some gaps in therecording of routine observations on Cherry Tree Wardand Apple Tree Ward.

• There was a critical care outreach team, who werepresent on site seven days a week. The team could becontacted by any member of staff, and their contactdetails were accessible on all wards, as well as on theobservation recording document. The ward staffreported that the outreach team were responsive to thepatient’s needs.

• Staff on several wards told us that when they escalatedconcerns regarding a deteriorating patient to themedical team, they were quick to respond at any time ofthe day, and would respond swiftly.

• On Walnut Ward we observed staff intervene at the earlysigns of a patient’s health deteriorating due to a lifethreatening complication (pneumothorax). The actionwas swift and resulted in a positive outcome for thepatient

Nursing staffing• The wards had recently completed the Shelford safer

staffing tool. Currently, in each area staffing levels werecalculated based on patient to staff ratio, which equatedto approximately one nurse to eight patients during theday. This model of staffing was not reflective of patientneeds, and wards, including Cherry Tree and Apple Tree,were not able to complete basic nursing tasks, due topatient dependency outweighing the staffing numbers.Therefore, there was an insufficient number of staff onduty to support dependency.

• Nursing numbers had been assessed for each ward.However, this was inflexible and staffing levels were notco-ordinated according to the patient’s dependency orneeds. Staffing cover was provided through the use oftemporary agency staff, while new permanent staff wererecruited into posts.

• During July, of the staff on duty in all medical wards,between 12% and 29% were agency or bank staff. InAugust, the percentage of bank and agency used wasbetween 9% and 26%. There was a higher use of agencystaff on Apple Tree Ward and Cherry Tree Ward.

• All nursing staff told us that the trust had difficultyrecruiting and retaining staff, although we met many

staff who had worked at the trust for many years. Onetold us “we can’t keep staff”. Doctors we spoke withwere aware of some nursing shortages, and reportedthat they were kept informed of nurse vacancies.

• Ideal and actual staffing numbers were displayed onevery ward we visited. During our inspection, boardsindicated that, in the main, the ideal numbers of staffwere maintained on those days. On Apple Tree Ward,there was a shortfall of a nurse and a support staffmember for an afternoon shift. The matron told us thatshe was trying to fill the shifts with temporary staff.

• Agency staff had an induction when they commencedtheir shift, which covered the ward layout, emergencyprocedures, and information to assist them withpatients’ care.

• Four patients we spoke with raised concerns about thenon-English speaking nursing staff. Patients all reportedto us that the staff were “lovely”, but shared that theywere unable to communicate with the staff. The trustconfirmed that action was underway to provide supportto those staff to improve their English.

Medical staffing• Currently, there were ward rounds seven days a week on

the Medical Short Stay Unit. There was an acute medicalconsultant on the unit from 8am to 8pm. After 8pm andat the weekends there was on-call consultant coveronly.

• We spoke with a range of junior medical staff, whoreported that working hours and shift time were betterthan any other training placement that they had beenon. No concerns were reported by staff on medicalstaffing numbers.

• Daily ward rounds were consultant-led throughoutmedicine, except for weekends, which had limitedconsultant rounds. We found that there was a handoverfrom consultant to consultant, and from junior doctor tojunior doctor on each shift.

• We observed MDT ward rounds, which were thorough,well organised, and well attended.

Major incident awareness and training• The trust had established an emergency planning

steering group to provide assurance to the board thatplans established were updated regularly. These planshad been developed in conjunction with the localhealth economy.

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• Staff within the local departments were unclear of thespecific requirements of their role during a majorincident. Staff were able to show us where the majorincident plan was, and who they would contact if theyneeded advice.

.

Are medical care services effective?


Medical care services were not effective as people were atrisk of not receiving effective care or treatment. Care plansdid not always reflect current evidence based guidance incannula care. Patients were offered a variety and choice offood; however, fluid balance monitoring was not alwayseffective. There were gaps in the managementarrangements and support for staff in regards tosupervision. We found that agency nurses and studentnurses were not always supervised sufficiently which led topoor care being delivered. Outcomes for diabetic patientswas below the national standard and patients we spoke toon site and at our listening events supported that care forpatients with diabetes was not as good as it could be dueto lack of understanding of the condition amongst nursingstaff.

There was no on site seven day cover for medical staff;cover was provided on-call and not on site. With theexception of support for respiratory services, there were nooccupational therapy or physiotherapy support services atweekends. There were also reported delays aroundmedicines, due to the pharmacy closing at 4.30pm, and notworking at weekends. However there were goodarrangements for multidisciplinary team working. Theservice had undertaken local and national audits. Length ofstay is in line with the England average for emergencymedical admissions.

The change in the facilities on Apple Tree Ward and theReablement Centre did not effectively support dischargefrom hospital. The service had increased bed capacity byfive beds on each ward, and taken away rehabilitationfacilities. This had had a negative impact on the length ofstay for patients.

Evidence-based care and treatment• The medical care service used a combination of

National Institute for Health and Care Excellence (NICE)and Royal College of Nursing guidelines to determinethe treatment they provided. Local policies were writtenin line with this and other national guidelines, and wereupdated every two years, or if national guidancechanged.

• There were specific care pathways for certainconditions, in order to standardise the care given.Examples included falls, sepsis and infections such asMRSA.

• There were care bundles in place to ensure thattreatment for the most common conditions, such aschest pain, reflected best practice and nationalguidelines

Pain relief• We observed staff provide medicines during the visits;

when medicines were administered, pain relief wasoffered to the patient or given as prescribed. Weexamined 15 medicine charts which supported ourobservations.

• Three patients on Cherry Tree Ward and four patients onApple Tree Ward told us that they regularly had to waitfor their medicines. Two patients on Cherry Tree Wardtold us that staff were “very busy” and did not give themtheir pain relief in a timely way. On Apple Tree Ward fourpatients all reported to us that there were delays inreceiving pain relief, despite requests to staff. Theyinformed us that they believed this was because therewere not enough staff on duty.

Nutrition and hydration• We observed on all wards that regular fluids were

provided. However, we observed that the recording offluid intake was not consistent. For example, on AppleTree Ward we noted a patient was on a fluid balancerestriction of 1500mls per day. This patient informed usthat they had to remind staff of their fluid balancebecause staff were not keeping track of what the patienthad already had.

• We observed a patient on Cherry Tree Ward who hadthree drinks provided to them during our observationperiod; all three were removed by staff during thecourse of our observation, and no details of the amountof fluid taken were recorded in the patient’s notes. Thispatient was on fluid restriction, and therefore fluidintake recording was required.

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• On day one of our inspection we observed on CherryTree Ward that fluids were out of the reach of eightpatients. We spoke with staff, who ensured that peoplehad drinks nearby. We noted that four patients haddrinks out of reach during the second day of theinspection.

• Patients were positive about the choice and quality offood offered to them. Patients reported that the foodthey were given was of a good quality. During theinspection we spoke with 23 patients about the food. Allwere mostly positive about the food; commentsreceived included “food is nice”, “there is a goodselection”, “they make me salads, I do like their salads”.

• Whilst all patients were complimentary about thequality of the food and the options, we receivedfeedback from three people that there was no option onportion size, and meal portions were often larger thanthey could manage.

Patient outcomes• Standardised relative risk of readmission for the trust

and Hinchingbrooke Hospital was lower than expectedfor all specialties, other than clinical haematology whichhad a value of 107. The ratio of observed to expectedemergency readmissions is multiplied by 100. Valuebelow 100 is interpreted as a positive finding, as thismeans there were less observed readmissions thanexpected.

• The Myocardial Ischaemia National Audit Project(MINAP) is a national clinical audit of the managementof heart attack. The MINAP audit showed that thehospital provided data as part of this audit, but noresults specific to the hospital were available at the timeof our inspection because they did not provide adedicated cardiac service.

• National Diabetes Inpatient Audit (NaDIA) participationshowed that the trust performed worse than expectedon five out of 22 questions, with the trust performingworse than expected in questions covering foot care,meal timing and staff knowledge. During our inspectionwe spoke with patients who corroborated this auditresult.

• Length of stay at Hinchingbrooke Hospital is in line withthe England average for emergency medical admissions.

• Walnut Ward is the medical ward which providesspecific respiratory care, including non-invasiveventilator care (NIV). During the inspection we wereinformed that patients on NIV could be placed in other

wards around the hospital, and there was an inpatientbeing NIV treated outside of Walnut Ward at this time.The staff on the other medical ward were not ascompetent as those trained on Walnut Ward. Other wardstaff are supported with NIV management by CriticalCare Outreach Practitioners of staff from Walnut.

• The medical care wards currently have a highoccupancy rate of patients. To accommodate thisincrease, the Reablement Centre and Apple Tree Wardhad converted their day rooms into additional patientbays. This had directly impacted the quality of carebeing provided to patients who required reablement tofacilitate their discharge.

• The trust provided us with a list of all ongoing andcompleted audits during their past year. Most were inline with expectations, except venousthromboembolism (VTE), which locally showed poorresults on Cherry Tree and Apple Tree Wards.

• The majority of national and local audits were ongoing.Where completed audits identified areas forimprovement in clinical effectiveness and outcomes forpatients, there were action plans in place to addressissues raised.

• The in patient survey showed that the trust wasperforming in line with national expectations in all areasof the questionnaire.

Competent staff• Nursing staff and medical staff we spoke with had

received an appraisal within the last year. We examinedthe appraisal data, which showed that 87% of acutemedicine staff, and 79% of care of the elderly staff hadreceived an appraisal.

• Doctors reported appraisal and revalidation taking placeaccording to General Medical Council guidelines.

• Bank and agency staff working at the trust are trained bytheir respective agencies. The management team on thewards were clear on the procedures for feeding backabout competency of bank and agency staff. We wereprovided with examples of when agency staff had notperformed in a competent way, and what action thehospital had taken to ensure that improvements weremade. We observed, in a case where a nurse hadinappropriately moved a patient by performing a draglift on them, that this person had been reported to theiragency, and the ward had requested that this personwas not sent back to the trust.

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• We were made aware during the inspection that thenursing establishment had raised concerns about thequality of care provided by some agency workers. Ondiscussion with senior nursing staff this information hadbeen escalated to the senior management team, whowere reviewing the concerns raised about agencyworkers.

Facilities• On Apple Tree Ward and in the Reablement Centre, the

day room facilities had been changed into additionalward bays, to allow for times of high capacity. The dayrooms on both wards were for rehabilitation, and werewhere allied health professionals, includingphysiotherapy and occupational therapy teams,provided rehabilitation support, to enable a quickerdischarge into the community.

• Both wards had increased their bed capacity by anadditional five beds, and had not had rehabilitationfacilities available for over two months. We spoke withthe nursing and medical staff about the change of thesefacilities to beds. We were informed by staff that they feltthe change in facilities had directly impacted patients’length of stay, as they were receiving less enablementtherapies. Therefore, the change in facilities was noteffectively supporting the discharge of patients fromhospital.

• The trust participated in patient-led assessments of thecare environment (PLACE). The hospital scored slightlybelow average for food, privacy, dignity and well-being.

Multidisciplinary working• There was clear evidence of multidisciplinary team

(MDT) working on the ward. There was regular inputfrom physiotherapists, occupational therapists andother allied health professionals, when required. Thelevel of information from MDT teams in patient recordswas comprehensively detailed, with clear plans andinstructions.

• There was evidence that the trust worked with externalagencies, such as the local authority, when planningdischarges for patients. However, senior staff reportedthat discharges were often delayed when dealing withsome social services departments. We were informed ofan example of a patient who had been an inpatient forover 100 days, despite being medically fit for discharge.The trust reported that this was a situation beyond thecontrol of the trust. This patients discharge plans wereescalated by the MDT to the executive team for action at

a higher level, we observed entries from the dischargecoordinator, nursing and medical staff regarding theseplan in the person’s medical records, though the personremained an inpatient at the time of our inspection.

• We found that the services were accessing the localauthority Deprivation of Liberty Safeguarding team toapprove and review DoLS applications for patients wholacked capacity to make decisions regarding their care.

Seven-day services• There was a medical presence on the wards seven days

a week. Consultants’ ward rounds took place daily insome areas, such as in the Medical Short Stay Unit, andin other wards at least once on a weekend. Medicalpatients on other wards would be seen by on-callphysicians if they became unwell, or if there wereconcerns about deterioration. We noted that the trustwas reviewing a business case to support the need foracute physician cover on site, seven days per week.

• Patients were seen by allied health professionals duringweek days. Support services, including physiotherapyand occupational therapy services, were not available atthe weekends. Nursing staff informed us that they aimedto follow care plans at weekends, to continuerehabilitation therapy with patients; however, they oftendid not have the time to complete this.

• Physiotherapists who gave respiratory support wereavailable on a call out basis at the weekends, and werecalled in when required for Walnut Ward.

• There was a daily ward round on the medicalassessment unit (MAU), including at weekends. Medicalpatients on other wards would not be seen routinely,and would be seen by on-call physicians if they becameunwell, or if there were concerns about deterioration.

• All medical care areas reported challenges with accessto the pharmacy service after 4.30pm daily, and at theweekends. All areas reported to us that the lack ofpharmacy support led to delays in treatment andpatient discharges.

Are medical care services caring?


Patients were not treated on Apple Tree ward withcompassion therefore we have judged this aspect of theservice inadequate. On Apple Tree Ward we observed poor

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patient experiences, and from our observations of care onthe ward we established that people were not treated withdignity or respect. We also found that on the ReablementCentre a patient who's needs had not been met and leftthem feeling undignified. We were concerned that peoplewere not being treated in an emotionally supportivemanner. We heard patients talk negatively about theinteractions that they had with staff on Apple Tree ward.Some patients were afraid of certain nursing staff on thisward. We heard some staff being rude to patients or beingdismissive of them. Some patients and relatives on AppleTree and Cherry Tree wards felt that they were not involvedin their care. We spoke with 23 patients during theinspection, and the majority, 17, were complimentaryabout the care they received from their local hospital butwe spoke with, saw and heard extreme examples of wherecare was inadequate.

Compassionate care• In the June 2014 NHS Friends and Family Test results,

three wards scored above the England average of 72%,for people who would recommend the hospital wards.

• Between September 2013 and January 2014, aquestionnaire was sent to 850 recent inpatients atHinchingbrooke Hospital, with responses received from413 patients. The ward areas scored on average with allother hospitals in England for care and treatment withdignity and respect.

• We spoke with 23 patients during the inspection, andmost were positive about the care they received fromtheir local hospital.

• We observed good examples of one-to-one care of apatient living with dementia on Cherry Tree Ward. Thehealth care assistants approach to the patient needswas calm and respectful.

• We observed that the way medicines were administeredby the staff nurse to patients in the Reablement Centrewas done in a caring and respectful manner. The staffmember took the time to explain each medicine andwhy it was needed to all patients we observed whoasked

Patient understanding and involvement• The majority of patients and relatives we spoke to

stated that they felt involved in their care. They hadbeen given the opportunity to speak with the consultantor the doctors looking after them. However we foundthat those without mental capacity did not always have

their best interests discussed with family. We spoke witha family of one patient who lack capacity who informedus that they were not involved in best interest decisionsbeing made for their relative.

• Some patients on Apple Tree Ward and Cherry TreeWard told us that they had not been involved in theircare. One said “they tell me what I need and thenchange their mind but don’t tell me”. Another patienttold us “I don’t know what is going on”, whilst anothersaid “I am told to take my tablets, but they don’t tell mewhat they are for”.

• Some patients and relatives said that they wereunaware of the arrangements for their discharge home.Some people made comments such as “no one tells uswhat is happening”, and “we are told different things bydifferent staff”, “it seems like no one knows what is goingon”.

Emotional support• Patients’ emotional well-being, including anxiety and

depression, were assessed on admission to each wardarea, and appropriate referrals for specialist supportwere made, where required.

• Clinical nurse specialists were available to offer adviceand support to patients and relatives about diagnosisand treatments.

Dignity and respect• On Cherry Tree Ward we observed that patients’

cleanliness and hygiene were not always maintained.This related to the cleanliness of people’s hands andfingernails. We observed five patients who had longfingernails, with dirt underneath them; their hands werealso unclean. On examination of three of the patientrecords, there was no evidence to support the patientrequirement of cleanliness and nail care.

• Our 'expert by experience' observed a poor interactionon Apple Tree Ward between a staff member and apatient. We observed the staff member push a tray tabletowards a patient after they pushed it away; this wasrepeated several times; when the staff member pushedthe tray back, soup spilt down the front of the patient.The staff member was then rude towards the patient forthe soup being spilt. This patient was treated in anundignified and emotionally unkind manner.

• We observed a lunch time meal on Apple Tree Ward. Wesaw that patients received help to eat their food where itwas required, but this was not always done in a way thatrespected the dignity of the patient. We observed a

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health care assistant helping one patient to eat somesoup. The health care assistant did not engage with thepatient and stood over them. We observed that thehealth care assistant was abrupt with the patient, anddid not respond to the patient’s attempts tocommunicate that they did not want any more of theirmeal. We observed this health care assistant assistingtwo people to eat their meals at the same time.

• We completed a SOFI observation on Apple Tree Ward atthe time that the night shift changed over to the dayshift. Short Observational Framework for Inspection(SOFI) is a specific way of observing care to help usunderstand the experience of people who use theservice, including those who were unable to talk with us.

• We heard the audible interactions of a patient who waswashed behind a curtain in the morning. The agencystaff member entered the bay and did not ask forconsent to wash the patient, and did not introducethemselves to the patient. The patient was heard to ask“who are you?” We also heard the patient ask if theywere clean and they said “I don’t feel clean”; this wasnot answered by the staff member who, after a shortsilence, instructed the patient to “roll on your side”.

• During breakfast we observed three members of staffstanding over the patients whilst supporting them withtheir food. The food was provided to the patient at a fastpace, and gave them little chance for rest in between.Two of the three staff members did not offer the patientsa drink during the breakfast. This is an undignified wayto provide support at meal times to a patient.

• We spoke with each individual staff member, whoproceeded to sit down and provide support to eat;however there continued to be little or no interactionwith patients.

• We spoke with five people on Apple Tree Ward abouttheir food. One patient told us that the portions weretoo large and they struggled to finish them. They alsotold us that they were “told off” when they did not eat allof their food. When this was explored further with thepatient, they informed us that “staff tell me off if I don’teat everything”. They were concerned about this, andsaid that they felt they must eat all their food.

• During our observations in the morning we saw apatient being supported by a staff member who wasstanding up and leaning over them. We heard the staffmember say to the patient “don’t misbehave you know

what happens when you misbehave”. We later asked thepatient what they thought the staff member meant bythis; the patient became withdrawn and was unable toprovide us with an answer.

• A patient on Apple Tree Ward, who required supportduring the night to go to the toilet told us that staff were“often too busy”. They said “they tell me to go in my bedand they will change me when they have time”. Thispatient was able to give an example of waiting twentyminutes for a nurse, by which time they had alreadyopened their bowels and wet the bed.; the nurseadvised them that they had to wait and it then tookanother twenty minutes before they were cleaned. Thepatient told us that they felt their dignity had been takenaway.

• A patient who was immobile with back pain said thatthey had waited over an hour in the Reablement Centrefor their call bell to be answered when they required thetoilet, and it had been too late when the nursesattended. This patient told us “I try to let them know asearly as I can but they don’t come, I don’t feel goodabout it”.

• Overall, the patients we spoke with reported that theyfelt the care was good on Apple Tree Ward. Our ownobservations led us to conclude that patients on thisward were not consistently treated with dignity orrespect or in an emotionally supportive andpersonalised manner. We were so concerned that wemade a referral to the local authority's safeguardingteam.

• We visited on the following Sunday lunchtime andfound that the number of beds on the ward had beenreduced. The staff available provided assistance witheating the Sunday dinner with dignity and respect andengaged in meaningful conversation with patients. Wesaw that call bells were responded to promptly andpatients were reassured appropriately. One patient toldus that the care they received had greatly improvedsince our last visit.

Are medical care services responsive?


The medical care services were not sufficiently responsiveto the needs of all patients.The Medical Short Stay Unit andReablement Centre were not utilised for their intended

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purpose. This was because they were often utilised asgeneral medical wards so patients using these wards didnot always get the therapy required to improve. Medicalpatients were not always classed as outliers in medicalareas despite requiring specialised care. This meant thatpatients did not always get to see their consultant teamduring their admission and that potential treatment fortheir individual condition may be affected. Patientsreported high numbers of overnight moves between wards.This was disruptive to all patients and not in line with thetrusts policy. Some patients did not find it easy to raisetheir concerns, they were unaware of the complaintsprocedure. Staff stated that they did not get feedback fromcomplaints that had been made.

There was access to specific support for people who hadmore complex needs, such as dementia and learningdisabilities. Patients had access to the support servicesthey needed, such as to therapists when they neededthem.

Service planning and delivery to meet the needs oflocal people• All medical wards were medical wards with small

elements of specialist areas. Walnut Ward providedsome respiratory and cardiac care, Cherry Tree Wardprovided inpatient care for people with dementia, AppleTree Ward provided rehabilitation stroke care. However,due to capacity, these services were not always used totheir potential, with people being moved to other wardsnot in this speciality.

• A medical termination of pregnancy service wasprovided on the Medical Short Stay Unit. The servicewas provided to women at less than 12 weeks ofpregnancy, and covered chemically-inducedterminations only. This service was provided inconsultation and joint working with the gynaecologyservice. However, We did not see any formalised careplan or care pathway for the undertaking of this serviceon the Medical Short Stay Unit despite the trust statingthat there was one. The pre-planning and arrangementswere undertaken through gynaecology.

Access and flow• Bed occupancy was above the national average of 89%

at the time of our inspection.• The average length of stay for medical care was above

the national average. This was attributed to issuesrelating to the accessing of care packages and care

facilities in the community. Between April 2013-April2014 the number of patients waiting to receive a carepackage in their home was 19%, against the Englandaverage of 10%; the number of patients waiting for acompletion of assessment for further care was 44%,against an England average of 19%. These care issuesresulted in delayed discharge as planning for dischargedonly occurred once the patients was medically fit fordischarge.

• The medical care service was working with thecommissioners and local authority across two counties,to find placements in the community for patientsawaiting discharge. There was confusion amongstfamilies on the discharge arrangements into thecommunity for their relatives. Five relatives we spokewith felt that communication from all stakeholders, whowere involved in discharge, was poor.

• Referral to treatment times (RTT) for all medicalspecialties, including gastroenterology, cardiology andgeriatric medicine, were all meeting standards, withmost services achieving 100% compliance with RTT,with the exception of gastroenterology andgynaecology, who achieved 98.3% respectively.

• If a patient in medical services was placed on a surgicalward, they would be classed as an outlier. However,when a medical patient required a specific service, suchas respiratory care, but was placed on the stroke ward,then they were not classed as an outlier. This meant thatthose patients, who should see a specific consultant fortheir condition, did not see them outside of thespecialist ward area. Consequently, the trust reportedthat patients did not always get to see their consultantteam during their admission.

• On the Medical Short Stay Unit patients reported thatthey could be moved at any time of the day, including atnight time. The trust policy recommends that patientsare not moved after 9pm at night; however, patients hadexperienced bed moves out of hours due to capacityissues. We spoke with senior nursing and medical staffon the ward who informed us that this did take placehowever they aimed to avoid this where possible. Thetrust do not currently measure the number of transfersthat take place after their deadline time of 9pm.

• The Medical Short Stay Unit is a medical area, ideallyused to provide care to patients for a period of up to 72hours. We found that on the ward, four patients hadbeen on the ward for over a week, and in one case, overtwo weeks. We were provided with examples by staff of

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recent patients who had been on the ward for morethan one month. This supports the view that the patientflow within the hospital is affected because the MedicalShort Stay Unit is not able to be responsive due tohospital bed capacity issues.

• The Reablement Centre is meant to be a ward thatprovides support to people to get back into thecommunity. At the time of our inspection, 14 of the 24patients on the ward were long-term nursing carepatients, and were not on the ward to use therehabilitation services. This was due to delays indischarge arrangements which may be out of thecontrol of the hospital however the trust reported thatthis did prevent people who required rehabilitation fromusing the services provided by this specificrehabilitation ward.

Meeting people’s individual needs• We observed call bell times on each ward throughout

the visit. We noted that in the Reablement Centre, out of25 beds observed, that nine patients did not havepatient call bells within reach. We raised this with staff,who checked and ensured that call bells were placedwithin reach.

• The trust has recognised from patient feedback thatthey need to audit a baseline of call bell response timesand make improvements. However, they had notplanned to start this project until October 2014.

• A learning disability hospital liaison nurse specialist wasemployed to provide support and advice to patients,relatives and staff.

• Support was available for patients living with dementiaand learning disabilities. Despite some staff telling usthat there was a specialist dementia team the trust hassince confirmed that they do not employ a specialistdementia team.

• Some leaflets and patient information were available indifferent languages on request. Translation serviceswere also available to be accessed 24 hours per day.Staff could demonstrate to us, when asked, how theseservices were accessed.

• Most patients on Apple Tree Ward and Cherry Tree Wardsaid that they often did not know who their namednurse was, although this information was written abovetheir bed.

• The Reablement Centre at the time of our inspection thearea was single-sex in each bay, because the ward was

being used as an inpatient long-stay medical area,rather than as a rehabilitation service. This was due tocapacity within the hospital, and capacity for bedswithin the community.

• The environment in each ward visited had beenrefurbished. Cherry Tree Ward had been refurbishedwith dementia-friendly themes, including differentcolours and signs to meet the needs of a person withdementia

• Pastoral care and multifaith support was available topeople on the wards. There was a twenty four hour perday seven days per week chaplaincy service available topeople to meet all faith needs.

• We viewed the food menus provided to patients on theward, these contained options for vegetarians, glutenfree and halal. One patient we spoke with requestedspecific foods that were lower in salt or sugar. Thesewere provided with their preferred dietary option. Thiswas supported by observing the food they wereprovided at lunch which was specifically created forthem.

Learning from complaints and concerns• The complaints process was outlined in information

leaflets, which were available on the ward areas. Fivepatients told us that they had been provided withinformation on how to raise concerns. However, this wasnot consistent practice on all ward areas.

• Senior nursing staff told us that complaints about theirareas were discussed at their meetings. We sawevidence of this in the meeting minutes. Nursing stafftold us that they were not always made aware ofcomplaints, and did not receive feedback aboutcomplaints, or learning from these. They also told usthat providing feedback was difficult, as it was notpossible for all staff to attend meetings.

• We spoke with two families of patients who were raisingofficial complaints during our inspection. Bothcomplaints related to missed medicines on medicationrounds. They told us that they felt they were beinglistened to, and that action would be taken.

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Are medical care services well-led?


We could not be assured that the delivery of high qualitycare was assured by the leadership and governancearrangements in place in the medical care services. Wefound that the culture of identifying, reporting andescalating concerns was not open. We found that teamswere not engaged, or felt enabled to raise concerns. Weidentified serious concerns around the treatment andsafeguarding of patients on Apple Tree Ward; when raisedto the leadership team of the ward, they did not wish toraise it to a higher level, or through their reporting ofconcerns strategy called ‘Stop the Line’, as they felt it couldbe managed locally.

Prior to leaving the trust on 18 September 2014 wereported our concerns to the local safeguarding authority.The following day we informed the Trust DevelopmentAgency (TDA) and held a management review. We decidedto request further information as we were consideringtaking enforcement action under our powers under Section31 of the Health and Social Care Act 2008 to reduce thenumber of beds available on Apple Tree ward. However thetrust took steps to do this and to improve care as seenduring our two unannounced inspections. Since ourinspection the TDA have given the trust significant supportto address the issues highlighted in our letter of immediateconcerns to the trust. We continue to monitor actions takenby the trust.

Locally, nursing staff were positive about the leadership ofnursing on Walnut Ward; however, nurses felt that nursingleadership was lacking on Cherry Tree Ward and Apple TreeWard; the trust confirmed that the Divisional Head ofNursing was on long-term sickness leave. Medical staff feltthat they were well supported by the clinical leads andconsultants within the service. Junior medical staff hadgood access to leadership, education and developmentthrough the clinical teams.

Vision and strategy for this service• Senior nursing staff we spoke with said that they did not

feel involved in the decision-making processes withinthe hospital. The structure within the directorate, andwithin the trust, was clinically-led by medical staff, andlacked nursing engagement.

• All staff spoken with were aware of the vision andstrategy for the service, and referred to the messagessent out by the trust management team and by Circle.

• The medical service has a five year strategy plan, whichfocused on community engagement, and the need toprovide more residential support to the elderpopulation.

Governance, risk management and qualitymeasurement• Wards used a quality dashboard and Safety

Thermometer to measure their performance against keyindicators. Where wards were consistently falling belowthe expected levels of performance, action was taken toimprove performance by the nursing leader’s clinicalleaders and specialist nurses.

• There were regular governance meetings; however,most junior staff we spoke with were unsure of howgovernance worked to improve patients care. Forexample, there have been concerns regarding the careof patients on Juniper Ward in the surgical service. Staffwe spoke with were aware that there had beenconcerns, but did not know what was being done toimprove the service. This meant that lessons learnt werenot being embedded across the hospital.

• Governance meetings covered areas for concern,complaints, nursing indicators, and plans forimprovements in the safe delivery of patient care.

• We reviewed the risk register for the medical service andfound that issues we had identified were not listed onthe risk register.

Leadership of service• All nursing and medical staff felt engaged in how the

service could work together through the clinical lead forthe service. Medical staff of all grades were positiveabout the clinical leadership shown by the clinical leadfor medicine.

• Senior nurses within medicine said that they feltconfident in the director of nursing, who had beenrecently appointed within the previous three months.Nursing staff were supportive of the managementdemonstrated by the nursing leadership on WalnutWard; however, other staff felt that the nursingleadership on the other medical wards was not asvisible as they could be. We were concerned about thenursing leaders on Apple Tree Ward. When concernsregarding the safeguarding and treatment of adults on

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the ward were raised, the nursing leadership deal withthe concerns that were raised locally, and failed toescalate the concerns appropriately to the seniormanagement team to get additional support.

Culture within the service• The trust has a whistleblowing policy, as well as the

‘Stop the Line’ procedure, for staff to raise concerns.‘Stop the Line’ is a slogan borrowed from themanufacturing industry, where every worker on theshop floor has the power to bring the production line toa halt if they sense any risk to safety. In a hospitalsetting, this means that all staff have the power andresponsibility to ‘Stop the Line’ on any activity whichthey think could harm a patient. ‘Stop the Line’ is one offour initiatives to improve hospital safety, as part ofCircle’s 16 point plan at Hinchingbrooke Hospital.

• We spoke with most staff about the ‘Stop the Line’initiative, and all could give an example of when theywould use the procedure; most scenarios involved safestaffing levels. Staff we spoke with felt that it would haveto be a serious or significant event to invoke theprocedure; we found that staff did not feel empoweredor able to ‘Stop the Line’. When asked why they wouldnot use the procedure, no specific answers were given.We therefore felt that the culture of reporting concernswithin the trust was not as open as it could be.

• We spoke with the senior nursing leads on Apple TreeWard about our observation findings and our concerns,and whether they would consider this a case to ‘Stopthe Line’. We were informed that whilst it did meet thecriterion, they would not 'Stop the Line' because theycould resolve it locally. This is not in accordance withthe trust’s 'Stop the Line' procedure.

• We escalated our concerns to the executive team,including the chief executive. The chief executivedeclared that the CQC team had called a 'Stop the Line'into the concerns on Apple Tree Ward. A meeting wascalled to review the concerns, also known as a ‘swarm’.'Swarms' aim to gather all the relevant people togetherto discuss a matter of particular importance, Thismeeting was attended by the senior leads for the service

and for the trust, to discuss the concerns. The meetingaddressed points including staff exclusion and the needto increase staff levels on the ward. However, themeeting did not include the importance of the need toreview the institutional culture on the ward. We weretherefore not fully assured how effective the meetingswere.

Public and staff engagement• The medical care service regularly sought feedback from

people who use the service. They demonstrated successin obtaining feedback, with achieving an above Englandaverage response rate to the Friends and Family Test,and the NHS inpatient survey.

• Each ward had a board displaying the latest responseinformation, along with a ‘you said, we did’ message,responding to suggested areas of improvement.

• Staff were aware of the improvement plans and changesto be implemented within the trust. However, on a locallevel, some staff felt disengaged from the leadershipwhen the focus was on capacity as they believed thatthe focus was on the targets rather than the delivery ofcare.

Innovation, improvement and sustainability• The refurbished improvements of Cherry Tree Ward,

which were specific to those with dementia, wereinnovative to improve the care of older persons.

• There were plans to improve the cardiology care onWalnut Ward, with the service opening six bedsspecifically to provide monitored cardiology care. Theplans included staff training and development incardiology skills.

• Following the inspection, we returned to undertakeunannounced inspections on Apple Tree Ward on twooccasions. We noted that the management team hadkept to their agreed bed numbers and had increasedstaffing numbers. We were also informed that theservice did not plan to re-open beds in the near future.However, at this time we are not assured that theimprovements on Apple Tree Ward can be sustained.

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Safe Requires improvement –––


Caring Inadequate –––

Responsive Good –––

Well-led Requires improvement –––

Overall Requires improvement –––

Information about the serviceThe surgery service at Hinchingbrooke Hospital includessurgical and orthopaedic wards. Operating theatres includemain theatres, gynaecology and obstetrics, and thetreatment centre. The treatment centre alsoaccommodates the pre-assessment and day surgery ward.The hospital saw 18,106 patients in this directorate in2013-14. Surgical service provision includes generalsurgery, orthopaedics, trauma care, ear, nose and throat(ENT), gynaecology, ophthalmology, and urology.

We visited all surgery services as part of this inspection, andspoke with five medical staff, four ward or team managers,36 registered nurses, other health professionals and healthcare assistants. We also spoke with two specialist and leadnurses within the surgical service. We spoke with 30patients, and examined 16 patient records, includingmedical notes and prescription charts, as part of thisinspection.

Summary of findingsThe surgical services require improvement becausethere were significant risks and deficiencies evidentacross four areas of our inspection domains. The safetyof patients was at risk due to delays in nurses attendingwhen patients call for help. In Juniper Ward there was aclear consensus from many patients that they were notcared for safely because it took too long for nurses torespond, in particular at night time.However the trustproduced data which demonstrated that the averageresponse time in the week prior to our visit was onaverage four minutes, this meant that this may havebeen an emerging issue. We found that there werecontinuing problems of medication not beingadministered as prescribed. Nursing care records andplans did not always reflect the current needs of thepatient, or have clear guidance of the care to beprovided.

Patient outcomes were good in certain respects, such aslow incidence of pressure ulcers, and low readmissionrates indicating successful overall treatment. Manyissues were evident and had been identified by thetrust, but action had not been taken to improve theissues or actions taken had not been effective. It was notevident that staff could easily raise issues they wereconcerned about, either in their own teams or acrossprofessional boundaries.

Surgery

Surgery


Are surgery services safe?


Improvements were required in safety of the surgeryservice. We found that risk assessments were poor, therewas a lack of changes made to care plans when patientsconditions changed and children were not receivingappropriate care in the operating theatre as there were nodedicated lists or they were not grouped together at thestart of a list. In ward areas, we found poor completion ofdocumentation of care. Although risk assessments relevantto the patients were mostly in place, these were sometimesinaccurate, and there was no respective plan of care, or theplan was not reviewed as the patient’s condition changed.We found that there were continuing problems ofmedication not being administered as prescribed. Therewere some areas in the care of children being infrequentlycarried out therefore some staff may not have beenregularly practised in techniques; however, outcomes datahas identified no area of concern in respect of patientsafety.

There was an incident reporting system in place, andreports of the performance were displayed for staff,patients and visitors to examine. Safety checklists wereused in operating theatres, and theatre staff were givenfeedback on quality of care. We found that in ward areas,the regular observations of patients were carried out, andearly warning scores completed to identify patients at riskof deteriorating condition. Ward areas appeared clean andusually uncluttered. There was good use made ofhand-cleaning systems.

Incidents• Data for 2013-14 showed that the surgical service had

low rates of pressure ulcers and falls, which are generalindicators of quality of care.

• Data for 2013-14 showed that there were 10 seriousincidents within this core service. These were mainlyslips, trips or falls, and grade 3 pressure ulcers.

• We spoke with ward managers in three surgical wards.There were clear arrangements for reporting ofincidents. Staff were informed of any incidents at wardmeetings and handovers.

• In operating theatres, incidents were collated anddiscussed at clinical governance meetings every two

months, but also at two weekly staff meetings, and onnoticeboards at the entrances to operating theatres.Changes to practices or procedures, or recent seriousincidents or near misses, were discussed at a teambriefing session, as required.

• Mortality and morbidity meeting were held monthly todiscuss recent cases where patients had died or carehad not progressed as planned. Medical staff alsoattended governance meetings every two months. Risksand safeguarding issues were discussed and any keylearning fed back to medical teams.

Safety thermometer• We saw that safety reports were displayed for staff,

patients and visitors to view in each ward area.• Ward managers showed us the audit checks they made

monthly on key indicators of patient safety and qualityof care. Staff in surgical services were given informationabout incidents and complaints, and staff confirmedthis and knew the rates of infection or falls in theirclinical areas.staff were aware of the causes of and ratesof infection or falls in their clinical areas and causes ofincidents. We saw that staff followed procedures andthey recorded their regular checks on patient’s positionto prevent pressure ulcers or patient falls.

Cleanliness, infection control and hygiene• There were sufficient hand-washing facilities, and

supplies of cleansing lotions for hand washing at entrypoints to clinical areas, and within the wards and bays.We saw that ward staff used personal protectiveequipment, and washed hands at appropriate momentsin providing care. We saw that all staff used the handwashing facilities provided on entering and leaving wardareas.

• In the ward areas there were sufficient side rooms toallow for isolation when necessary. Juniper ward hadfive side rooms out of the 30 beds. There were nopatients on isolation at the time of our visit but nursesdescribed the precautions they would take. We spokewith one patient who had initially been isolated due toan unknown infection risk. The patient describedprecautions that nurses and visitors had taken onentering and leaving the room.we found these to beappropriate.

• Data for 2013-14 showed that the surgical service hadlow rates of catheter-related urine tract infections.

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• We observed good cleaning arrangements andprocedures in operating theatres. Staff cleaned areasand equipment between cases, and equipment andconsumables followed a clear flow through from cleanto dirty areas.

• There were inconsistent facilities for hand washing indifferent operating theatres. Staff were maintainingsafety by using scrub sinks to wash hands whereneeded, but there were no alcohol gel stations outsidesome entry points to the department. Taps for handwashing and scrubbing up were 'non touch' in maintheatres, but this was not the case in the treatmentcentre theatres. However the trust reported that thesetaps were compliant with current guidance.

Environment and equipment• We examined checklists and resuscitation equipment in

the surgical wards and operating theatres. Resuscitationequipment in each ward was checked routinely, andthere were clear records to evidence that this had beencompleted.

• Ward areas had emergency resuscitation equipmenttrolleys easily available in main corridor areas. Weexamined these and saw they had been checkedroutinely and were safe and ready for use.

• In operating theatres, recovery staff checked and signeddaily, to show key equipment and trolleys were safe andready for use

Medicines• We found that in Juniper Ward there were medication

omissions which meant patients were not receiving theexpected treatment, and their health and welfare couldbe at risk. One patient said they had been worried thatthey were not given their usual pain control tablet, andalso missed a regular aspirin tablet for three days. Thepatient was known to have a risk of thromboembolism.We discussed the case with the pain specialist whoadvised that these tablets could and should have beengiven despite the order for clear fluids in this patient.Another patient’s medication chart showed no record ofa prescribed anti-embolism injection without anydocumented reason for the omission.

• We discussed the omissions with staff, who said that thespecific omissions we noted in charts for the week priorto our visit had not been identified before ourinspection and would be recorded on the trust incidentreporting system.

• We examined storage areas for medication in ward areasand found appropriate security and temperaturechecking was in place. We observed that nursing staffwere careful to keep medications locked safely whenthey were not in attendance.

• In ward areas we found there was good support ofpharmacy. We saw that pharmacy staff visited the wardsand checked through prescription charts to ensureappropriate supply of medication and advice to nursingand medical staff. Pharmacy staff were aware thatmedication omissions had been occurring in surgicalwards and said that where this happened theydiscussed the recording issue with nursing teams.

Records• We examined 16 patient care records in ward areas and

operating theatres. We found that staff in surgical wardshad completed standard documentation as appropriatefor their patients. This included documents assessingthe risk of pressure ulcers, nutrition, moving andhandling, and venous thromboembolism. However, wefound that risk assessments were not always reviewedas the patient’s condition changed, and that respectivecare plans were not always detailed enough. Fiverecords reviewed in Birch ward had no follow up reviewof the initial assessment of risk of venousthromboembolism when they should have beenreviewed. However data provided by the trust showedthat patients were not at an increased risk of developinga venous thromboembolism under their care.Thismeant that staff may not provide the appropriate care tomeet the changing needs of patients.

• There were gaps in care planning for pressure ulcerprevention. We found that risk assessments for skinintegrity had only minimal detail of the care to be put inplace to prevent pressure ulcers developing. The trusthad sufficient pressure relieving equipment available forstaff to use. Risk assessments for skin integrity werecompleted on admission. We examined nine carerecords where an elevated risk of developing pressureulcer had been identified but there was no plan of carecompleted for staff to follow that was related to theidentified risk. We saw that staff entered a record of skinintegrity checks and other personal care each shift.There were records on charts to show that the patient’sposition had been checked or changed. However it wasnot evident from care records that a clear plan had beendecided following risk assessment. Staff told us that

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they were given information about key risks and thecare to be provided at handover, and on handoversheets. This meant there was a risk that staff might notbe aware of patient care needs to prevent pressureulcers. However the trust had a low rate of pressureulcers acquired in care.

• There was good documentation of pre-assessment forpatients preparing for surgery. Key risk information wasalso provided to the anaesthetist and surgeon as analert, where this would improve patient safety. We sawthat a risk of venous thromboembolism had been notedat pre-assessment for two patients who we spoke with.This information had been reported clearly in the careplan and medical notes.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards• We saw in patient records that consent to surgical

procedures had been clearly discussed with, and signedfor, by patients.

Safeguarding• Staff in surgical services knew how to report

safeguarding concerns to their manager to protectpatients from abuse. Staff in ward areas were able toshow us the policy and procedures for the safeguardingof vulnerable adults. Staff knew there was asafeguarding lead for the Trust and would use thisperson for advice where needed. In operating theatresstaff showed us the policy section on the intranetincluding safeguarding of vulnerable adults andchildren.

• We spoke with the matron in a ward area about apatient who considered that another patient who wasconfused and agitated had been handled roughly backinto bed at night time by nursing staff. The matron toldus they would take appropriate action to investigate,would inform the safeguarding lead and follow Trustprocedures for reporting. The overall review of thismatter was not yet concluded.

• A patient in day surgery ward told us they felt they hadbeen handled roughly by a junior member of staff. Wefound that the ward manager was aware of this, and wasinvestigating the issue.

• We found that there was no dedicated operating forchildren or that they were placed on the beginning of anoperating list. This meant that there was risk to childrenthat the appropriate staff were not available. There wasno paediatric-trained theatre nurse employed since a

nurse had retired in May 2014. Some staff had aninterest in paediatric care, and had completed specificpaediatric training courses, including safeguarding ofchildren to Level 3. During our inspection only 16 out of31 staff had undertaken Paediatric Intermediate LifeSupport training. When we raised this with the trust theytook action to ensure that children were safe within theoperating theatre department.

Mandatory training• There were good arrangements to enable staff to attend

mandatory training. Staff told us that they weresupported to complete mandatory training by theirmanagers. Some staff told us that they had undertooksome computer-based training in their own time.

• Records for the year to March 2014 showed that staffacross surgical teams had attended statutory trainingon moving and handling, safeguarding of adults andchildren, and information governance with around 90%of staff completed these sessions. There werecomparatively low rates of attendance at basic lifesupport ranging from 40% to 80% for the surgical teams.This meant that staff in surgical areas where patientscould be at risk of collapse were not fully updated inbasic life support.

Management of deteriorating patients• We found there was accurate use of early warning scores

on observation charts in the ward areas we visited. Staffin wards and operating theatres were aware of theprocedure for early warning scores, and the process forescalating information and action to ensure promptresponse to deteriorating patients.

• We saw that theatre teams were using the World HealthOrganization’s (WHO) ‘5 steps to safe surgery checklist’,which is designed to prevent avoidable mistakes; thiswas an established process with the teams. Weobserved effective communication during a teambriefing prior to the surgical list. Audit results showedthat post operation debriefs were completed only after92% of operations. This meant that opportunities forlearning could be missed. Overall audit results for WHOchecklist from March to July 2014 ranged from 97 to100%. The audit results shared with staff alsohighlighted issues such as the formality of team briefand that all staff questions had been addressed beforethe procedure went ahead. This meant that the theatreteams continually monitored and reported on processesto prevent avoidable mistakes.

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• The patients paper section of the theatre recordshowing the time that a patient left the operatingtheatre was not being completed by theatre or recoverystaff. This meant that individual records were not fullycompleted despite it being completed in electronicformat.

• In operating theatres staff kept clear count ofdisposables and other items, to ensure that all itemswere accounted for at the end of the procedure. Thiswas a clear visual safety procedure to prevent foreignbodies being left in the patient. Records were made incare plans and signed as accurate by two designatedstaff. Staff told us of a case where a patient had beenrequired to remain in an operating theatre while checkswere made. The remaining item was located andremoved.

• Delicate airway procedures in the operating theatreswere infrequently carried out on children. This meantthat staff may not have been regularly practiced in thetechniques due to low numbers of children using thesurgical service. Staff told us that they were aware of theneed to maintain competence. Since our inspection thetrust reports that enhanced support for consultantsdealing with emergency paediatrics has been put inplace and a facility to provide mentored practice withelective paediatric anaesthetics offered.

Nursing staffing• Staff in surgery wards and operating theatres told us

that they usually had sufficient staff. There werespecified staffing levels for each ward area, dependenton bed numbers and types of patients. Staffing rotasthat we examined showed staff levels had beenmaintained for the two weeks prior to our visit. On thenight shift there were three registered nurses and two orthree health care assistants on a 30 bed surgical ward.Additional staff were used where patients with higherdependency or were in the ward.

• However, we found that many patients in wards told usthere were not enough staff, in particular on night duty,which meant that patients had to wait too long for callbells to be answered when they required care orsupport. The majority of the patients we spoke with onJuniper Ward told us of this issue. Patients were veryclear that during the night shift it was often over 30minutes before patients were attended to when theyrang the call bell.

• Patients in the acute trauma surgical unit also told us ofdelays in call bells being answered. We observed the callbell response time on two occasions during thedaytime, and noted that it took ten minutes for a nurseto attend patients requiring the toilet.

• Ward managers told us that replacement staff wererecruited to maintain the agreed safe staffing levelswhen there was vacancies. In operating theatres we sawthat staffing levels met the guidance from theAssociation for Perioperative Practice, with two scrubpersonnel where required, one anaesthetic staff andone circulating staff member. Operating departmentpractitioners told us that staffing levels were maintainedat safe levels. The team would not allow operations toproceed without the required safe complement of staff.

• We saw that additional staff were arranged when aspecific need was identified, such as several patients atrisk of fall. Where an acutely ill or confused patientrequired constant supervision or monitoring, a memberof staff was allocated. Additional staff, such as agency,were arranged when required. We spoke with an agencynurse who had been caring one to one with a patientwho was agitated and confused and at risk of falling.

• We spoke with an agency nurse, who told us they hadmandatory training checked prior to working in thesurgical ward areas, and they had been given clearguidance about the ward area and procedures such asfor emergencies when they arrived for work. The nursesaid they had worked in the ward and other wards in thehospital on previous occasions.

Medical staffing• Data showed that in surgery there was a higher

proportion of consultant grade staff at 42% comparedwith the national average of 40%. There was lowerproportion of registrar level staff at 8% compare to theEngland average of 38%. Junior and middle grade staffmade up 50% of the medical staffing compared with24% nationally. There was a total wte of 84 medical staffin surgical services.

• Patients told us that they had regular reviews of theircare by medical staff, and were aware who theconsultant was leading their plan of treatment

• We saw that consultant staff visited ward areas regularlyto see patients, and ensure progress of patientpathways.

• There was support of specialists from the critical careunit if staff had concerns about a deteriorating patient.

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Major incident awareness and training• Staff in operating theatres showed us detailed plans and

procedures to follow in the event of a major incident.There was a file of the major incident plan held in maintheatres office and staff also showed us the full plan onthe intranet in operating theatres. We saw that staffcontact numbers had been updated as staff joined theteam so that additional staff could be called to help in amajor incident.

• Some ward staff were unsure of where the informationwas located about major incidents, but told us thatcontact numbers were kept by their manager, and theycould be called to support if needed in a major incident.

• Operating theatres used an electronic system foroperating lists. There were clear arrangements to useprinted lists if the IT system failed.

Are surgery services effective?

Improvements were required in effectiveness of the surgeryservice. We found that there were a number of areas whichrequired improvement including a lax approach to fluidmanagement, gaps in care records, and ineffectivecommunication between shifts. This meant thatinformation about patients’ needs was not alwaysconsistent. The multidisciplinary team worked welltogether but patients told us that the medical staff had notrecognised the issues in nursing care. Patients said thatmedical staff were aware of lapses in communicationleading to delayed diagnostic testing, and missedmedications for example. We saw that managers wereaware of trends showing missed medications and incidentreports provided by teams about staffing levels. There wereno plans in place to resolve the issues with missedmedication although these continued to be monitored bythe pharmacy teams.

In general, the data showed that surgical admissions weresuccessful, in that patients were discharged followingtreatment, and had not been readmitted. Pre-assessmentof patients and planning of operations lists was effective inscreening and preparing patients for surgery.

Evidence-based care and treatment• We saw that NICE guidelines were followed for care of

patients in the surgical service. Additional guidance wasavailable to staff to ensure good practice in managingcare.

• Specialist nursing staff described the NICE guidance thatwas followed for care of patients relating to pain controland hip fracture management. We saw thatdocumentation in care records to guide staff each daypost operatively for hip replacement followed NICEguidance for recovery. Therapy staff told us theyfollowed guidance for mobilisation following surgery.We found that guidance was followed on good practicein stoma care in collaboration with local clinicalnetworks.

• The operating theatre team used the intranet routinelyfor staff to easily locate and refer to policies andprocedures.

• Infection control policies were clearly displayedincluding hand washing throughout clinical areas. Inoperating theatres the uniform policy was displayed toremind staff of infection control measures related touniforms worn out to different parts of the hospital.

• Surgical staff held monthly mortality and morbiditymeetings, and there were governance meetings everytwo months to learn from experience. Medical staff toldus that risks and safeguarding issues were discussed.There was regular feedback from these meetings at staffmeetings and daily briefings if required. Medical stafftold us that they knew how to escalate issues if needed.The ‘Stop the Line’ procedure used to invoke if a seriousconcern was raised by any member of staff had beenused by theatre staff. The successful use of the processhad given staff confidence to speak out if they had anyconcerns for patient or staff safety.

Pain relief• There was an established system to ensure

post-operative pain of patients was managed effectively.A pain specialist nurse visited patients in ward areas toassess the pain with the patient, and support nursingand medical staff to revise pain control where required.

• We saw that pain control was managed, using agreedguidance in folders on each surgical ward, although thiswas only specified for patients following an operation.Patients on surgical wards who had not undergonesurgery were not routinely referred for painmanagement advice but the trust reported that thesepatients were referred as required.

• We spoke with patients who had been assessed by thepain specialist nurse. Patients told us that their pain waswell managed following surgery.

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• Two patients who had not had surgery told us that theirpain had not been managed well. One person said thatthey had a syringe driver with pain control which had,on two occasions, become empty of the medication,leaving them for some hours without any control of theirpain. Another patient with chronic back pain told us thatthey had to wait several times for over half an hour, for‘as required’ medication. This was because nurses hadnot answered the call bell quickly enough.

• One patient told us that ward nursing staff had notadministered some of their pain medication in the firsttwo days of their admission, due to the patient being onclear fluids. However, the pain specialist nurse told usthat part of the medication could have beenadministered in order to maintain the comfort of thepatient.

Nutrition and hydration• We saw that risk assessments had been completed in

care records, to check if patients required extra supportor monitoring for their nutrition and hydration. Wefound that fluid charts and food intake records weremostly completed and summarised accurately.

• However, in three cases where we had observed care inthe ward, and spoken with relatives who had been inattendance, we saw that fluid intake had been poorlyestimated. We saw also that calculations of total fluidintake were not always accurate.

• One visitor told us that they had been concerned aboutdeveloping dehydration in their elderly relative. Theysaid they had been asking for several hours for a doctorto review the patient’s condition and to ensureadequate hydration. Another relative told us that theyhad been with a patient for four hours, tryingunsuccessfully to get them to take a drink, and nurseshad not offered any support. We saw that the ward wasbusy, with staff attending another acutely ill patient. Wespoke at length with the relative and examined the carerecord. Charts of fluid intake had not been completedsince the previous evening, the relative had been withthe patient from 6am to 11am trying to get the patientto drink through the morning. We saw that the patient’sposition was difficult for drinking, it was only afternurses supported the patient with personal care andchanged position that fluids were taken. We found thatrough estimates of fluid intake were then added to afluid intake chart.

• We saw that patients were usually offered drinksregularly during the daytime. Staff who undertook thistask were aware of who was able to take drinks. Wespoke with staff providing drinks and found that theywere also part of the nursing care team and fully awareof patient’s nutritional needs such as diabetic orsupplementary diet. We saw that patients had wateravailable with clean jugs and beakers. There were clearnotices above the beds where patients were designated‘nil by mouth’.

Patient outcomes• Data showed that in 2013-14 the length of stay for

patients undergoing bowel surgery was worse than theEngland average. 83% of patients stayed in hospitalmore than five days compared with the national figureof 69%.

• Data showed that in 2013-14 the length of stay forpatients undergoing hip fracture surgery was slightlyworse than the England average. The mean length ofstay was 22 days compared with the national figure of 19days

• Data showed that in 2013-14 the ratio of observedreadmissions was lower, which was better overall, whenreviewing all types of surgical patients, atHinchingbrooke than the expected rate compared to theEngland average. This is an indicator of effectivetreatment and discharge planning. However for electiveorthopaedic and ophthalmology cases in 2013-14 therelative risk of readmission was slightly higher than theexpected figure for the year. We saw that dischargechecklists were completed in case records for thepatients where we examined the notes of patients whohad a complex condition or continuing need for supportafter discharge.

• The National Audit of patients with bowel cancer in theTrust had shown that 28% of patients were seen by anurse specialist compared to a national average of 88%;however, this data related to a historical period whenthe specialist covered only part time hours. Thespecialist nurse role is now full time and 95% of patientsknow their specialist nurse, which is higher than themore recent national average of 91%.

• A high proportion, 54%, of patients who had bowelcancer had their surgery carried out as an emergency,compared to the national average of 18%.

• In the national hip fracture audit the service had worsethan the England average of 96% performance for

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having a specific falls assessment as 75% of patientswith hip fracture were recorded as having theassessment. A falls audit, undertaken by the trust inAugust 2014, did not specify the patient diagnosis butreturned a falls risk identification rate of 91% acrossseven wards. Areas for improvement, together withplanned actions, were included in the audit report.

• The trust had better than average performance fordevelopment of pressure ulcers at 1.5% compared tothe national average of 3.5%.

• The trust had better than average performance at 91%for making bone health assessments of patientscompared to the national average of 85%.

Competent staff• We saw detailed documents that staff in operating

theatres used to ensure competency in specific duties. Acompetency booklet for scrub practitioners and theatresupport workers covered the competencies related toperioperative care and specialist surgery, such asorthopaedics or ophthalmology. Staff completedcompetency checks for new skills, but told us that therewas no review of competencies. This could mean thatstaff lose skills not practised and checked regularly, andmay not undertake skills safely: however the trust toldus that staff were issued with a revised competencypack between July and August 2014, which involvescompleting a separate annual review document.

• In a focus group including five theatre staff we heardthere was good access to training, they worked as asupportive team and staff felt able to ask for support ifthey required advice. New staff in operating theatreswere employed under a probationary period, withchecks on competencies at three monthly intervals forsix months.

• Two health care assistants we spoke with told us thatthey had annual training updates on key skills. Thisincluded taking observations and use of the earlywarning scores to ensure nursing and medical staff werealerted if patient’s condition was deteriorating.

• Medical staff told us that they had good facilities andsystems for personal development, and this had meantsome staff developing in their career through toconsultant level. Facilities included video links fromoperating theatres to seminar rooms, to enableobservation and shared learning from current practice.

Multidisciplinary working• Staff in operating theatres told us that there was

effective working across paediatric services of the trustand the Cambridgeshire Community Trust staff, whomanaged the paediatric wards on the same location.There were meetings every two months to discusscollaboration on paediatric services.

• Staff told us that there was good multidisciplinaryworking in ward areas to plan care and promoteeffective discharge. We saw that there were ward teammeetings early in the day at handover which includedtherapy, nursing and medical staff. Notes were takenand key care issues were noted in a communicationbook in addition to patient records.

• Specialist nurse advice was available to staff regardinginfection control, and pain management. These staffprovided clinical updates to link nurses for cascadewithin the ward teams.

• Patients told us about communication issues that hadcaused delay in their diagnostic tests. One patient on award told us that they had waited four days for anultrasound scan. They said they had been to the scandepartment three times, only to be turned away andsent back to the ward due to mistakes in bookings.Another patient told us they had been taken to aprocedure room only to be told they would have goback to the ward and wait another three days untilantiembolism medication had worn off. The trustsupplied evidence which demonstrated a low level ofdelayed diagnostic tests, with eight incidents occurringin the previous 18 months.

• There were some problems for patients regardingcommunication of care needs between shifts of staff. InJuniper Ward, one patient, and relatives of two otherpatients, told us that they felt there was poorcommunication about aspects of care. They said theyhad to remind staff of key aspects of care or treatmentthat had changed, but which the staff on a new shift hadnot been aware of. Two patients told us that they feltthey had to manage their own care, remind staff forexample about problems with infusions, to ensuretreatment was consistent. One of these patients saidthere was a risk that other patients, who were not soaware, or able to articulate their concerns, may receiveinconsistent care.

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Seven-day services• There were clear arrangements for medical staffing.

Doctors of grades FY1 and FY2 told us there wasconsistent consultant cover when required, including foradvice out of hours.

• Staff in surgical areas told us that patients needingurgent X-ray at weekends sometimes had to wait forseveral hours due to the availability of on-callradiography staff, in particular, if X-ray support wasrequired in operating theatres. This was the case whenwe visited out of hours, staff in A&E stated that patientswere awaiting x-ray due to the radiographer being inoperating theatres.

Are surgery services caring?


'The surgical service was rated in this domain asinadequate as, although many areas of surgical careprovision were meeting or exceeding required standards,patients’ basic needs were not being met in all cases. 17out of 30 surgical inpatients told us that they had to waitunacceptably long periods when they called for assistance.This resulted in some patients not receiving care at theexpected level required to protect their dignity. Twopatients told us that they had been told to soil themselvesand a further one patient stated that delays resulted inpatients soiling themselves. Five patients told us that therewas little time for nurses to provide emotional support andexplanations about care to patients and relatives, althoughit is recognised that this is not a role limited to nursing staff.Fifteen patients also told us that they had had experiencesof nurses being kind and considerate in providing care.

Compassionate care• Patients told us that most nurses and staff were kind

and compassionate, but that there were many timeswhen the care had been poorer quality than theyexpected. A comment that many patients gave was thedelay in being attended to when calling for help.Patients also described a lack of attention to otherissues such as keeping the bed area clear when patientswere unable to get out of bed. One patient and relativesaid the bed had been surrounded by numerous urinebottles by the end of a day as they had been asked tokeep samples for measuring.

• Many patients across all surgical wards told us that theyhad to wait half an hour or longer when they werebed-bound but required a nurse to use the toilet. Thetrust provided evidence of a call bell audit undertakenby the trust on Juniper ward in the week prior to ourvisit that indicated that waiting times ranged from 2 to 8minutes, with an overall average of 4 minutes from callto response. The concerns raised with us by patientsmay have been a recently emerging risk however thiscould not be confirmed.

• Two patients in surgical wards reported that care staffhad responded briefly to the call bell, advised thepatient to go to the toilet in the bed, and that theywould be made comfortable as soon as they were ableto attend the patient. The patients said that nurses werecaring and supportive at these times but they could notattend quickly enough to help maintain the patient’sdignity. Staff agreed that at night time they often foundit difficult to respond quickly enough to calls frompatients. They explained this might happen if there werestaff on breaks and remaining staff were busy with otherpatients.

• Three patients in Juniper Ward told us that they had togo out of their bay to find a nurse to help patients whohad been calling for help but the call bell was notanswered. There were quiet sliding doors across bayswhich helped to maintain a quiet environment for rest inbays. Patients said this meant the nurses could noteasily hear patients calling out for help when the callbell was not used; however, this was not substantiatedvia nursing staff

• There was agreement among the 12 patients we spokewith on Juniper Ward that the response of nurses to callbells was routinely poor at night time. They told us thatthey were aware nurses were busy with other patients atsuch times.

• In March, May and June 2014, the score of the Friendsand Family Test of whether patients would recommendthe service on Juniper Ward was between 61-66%. Forother surgical wards where data was available, we sawthe score was over 95% for the same months.

• In operating theatres we saw that the privacy anddignity of patients was protected. Curtains were used ifpatients were sharing the same bays in reception andrecovery areas. Clear notices were used on curtains inthese instances to designate the patients behindcurtains to support good patient identification.

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• One patient on the acute surgical and trauma ward saidthat they had been on seven wards in the first three daysof admission, and had been moved at 12.45am, 3amand 5am on different days. The patient recognised theneeds of more acutely ill patients, but said it had beendisruptive to rest and sleep early in their admission.

Patient understanding and involvement• Patients told us that nurses introduced themselves at

the handover of shifts. Patients said, however, that therewas little continuity and there had been many differentnurses across the shifts in the week.

• The views of patients were taken into account inoperating theatres. Staff had used a survey to gatherviews of patients about anxiety and feelings through theprocedure. As a result of feedback, more time wasallowed for patients to talk with the anaesthetist orsurgeon in the perioperative period. Additional patientsatisfaction surveys were being undertaken at the timeof our inspection.

• Patients told us that the care provided by nursing staffwas not effective, due to poor response to call bells andlack of continuity of information from day to day,meaning they had to ensure for themselves that staffwere providing consistent care. One patient told us thatthey felt medical staff had not recognised or tried toaddress these issues in the nursing teams.

Emotional support• Patients in Daisy Ward told us they were cared for with

compassion, and staff responded well to their needs.Two patients told us that in Juniper Ward the nurseshad little time to provide emotional support. They saidnurses were kind and supportive when they were able toattend patients. They told us that nurses only had timeto provide the technical and physical care. One relativetold us that they had to ask several times before stafffound a person who was able to explain the treatmentand plan of care.

• We saw that parents accompanied their childrenthrough to the anaesthetic room prior to surgery, andwere able to be with children as they awoke from theiroperations.

• In the pre-assessment unit, patients were met by amember of the nursing team, and directed to theappropriate room for their appointment. Patients told

us that this was reassuring and welcoming. We saw thatpatients were given adequate time to answer questions,and to ask if they were unsure about their forthcomingoperation or procedure.

Are surgery services responsive?

Good –––

Surgical services were good, because we found examplesacross the service that showed flexibility andimprovements to enable access to the service. Patientswith learning disabilities were supported effectively toaccess surgical care. There was a good surgicalpre-assessment service, which was designed to ensuretime to capture relevant information, to promote safety,and to provide a seamless experience for patients.

We found that patient feedback had not been usedeffectively to identify issues and plan improvements tobasic care provision.

Service planning and delivery to meet the needs oflocal people• The trust was meeting 18 week referral to treatment

times (RTT) for all surgical specialities.• There was an effective pre-assessment department,

which supported patients in preparation for theiroperation. There was good flexibility in pre-assessmentto provide this service in a way or place that wasconvenient for patients. Pre-assessment was beingoffered to some patients as a telephone service whereappropriate. In the pre-assessment unit, the staffidentified when clinic appointments were available, andmade these available to the outpatients department.This meant that some patients were able to have theirpre-assessment for admission on the same day as thedecision to admit was made in the outpatients clinic.

• Patients for surgical team care were regularly cared foron medical wards. Three patients in the orthopaedicward told us that they had been moved several timesbefore arriving on the surgical ward. This was areflection of high occupancy of beds in the hospital andhow patients were accommodated if admitted in anemergency. Although a nurse in charge of acute traumaward stated it was rare to move patients at night wewere told by patients that they had moved at nightwhen beds were needed for emergency admission.

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Access and flow• There were clear arrangements and procedures for

access to the surgical service. Patient booking forsurgery and surgical lists was managed effectively.Operating theatre lists were managed by the consultantsurgeons, with administration support, and incollaboration with surgical practitioners and theatreteams. This intensive planning meant that there werefew cancellations of patient operations. Where theatrelists overran elective patients were operated on usingthe capacity of the emergency theatre teams. Since July2013 any patients whose operations were cancelled hadtheir procedure rebooked within 28 days.

• Data showed that in 2013-14, the delay from referral totreatment (RTT) was consistently better than theEngland average and national standard of 90%. Allsurgical specialties were meeting RTT standard oftreating patients within 18 weeks. All specialties atHinchingbrooke were over 90%. General Surgery 92.2%,Trauma & Orthopaedics 91.9% Plastic Surgery 97.0%ENT 94.4% Urology 99.7% Ophthalmology 95.4%.

• Ward managers and staff told us that dischargeplanning was reviewed regularly. The plans werediscussed with patients during medical staff wardrounds. Progress on discharge arrangements waschecked by the team in daily briefings, handovers andmultidisciplinary meetings. This process was confirmedby therapy and pharmacy staff in ward areas. We foundalso that discharge checklists were completed in thecare records that we reviewed.

Meeting people’s individual needs• The operating theatre team held a Saturday club for

children to look round the facility prior to coming in for aprocedure. There were bays decorated to help childrenfeel relaxed within the clinical area.

• There was good flexibility in supporting people, such asvulnerable patients with complex needs. Patients whowere identified as being vulnerable in any way, such asfrail, confused or with learning disabilities, had specificattention paid through the use of a checklist, to assesscapacity, the patient’s understanding, and any anxietyabout the procedure. Additional support wasconsidered and planned at the pre-assessment stagewith the patient and relatives where appropriate. Staff inthe operating theatre described their flexibility inproviding support for a patient who had a complex

mental health condition. The patient had been anxiousabout anaesthetic and theatre rooms, and so had beenanaesthetised in the recovery area before being takenthrough for the procedure.

Learning from complaints and concerns• Ward managers and staff in surgical wards told us that

they used complaints to learn lessons and improve theservice. However, we found that patients in all areasdiscussed problems with us, such as poor response tocall bells, and lack of time to talk with patients. Therehad been clear indications that satisfaction was reducedfor three months earlier in 2014 but the reasons for thishad not been established or tackled in the relevant wardarea.

• Patients knew how to complain and said they wouldspeak to the nurse in charge or the ward Matron. Theytold us about some complaints they had made. Onepatient had complained about noise from outside theward window which had not been stopped quickly atthe time, but the patient had been reassured that theissue had been investigated and the cause of the noisehad been dealt with.

Are surgery services well-led?


Surgical services required improvement because, althoughthere were some systems in place to audit quality of care,they had not supported improvement. The staff andmanagers were aware of medication errors but a clear planfor improvement had not been developed. Documentationaudits were being completed and reported but we foundthey were ineffective at identifying gaps in care planning.Patient feedback had clearly indicated a reduction insatisfaction from March 2014, but this had not been metwith any plan to improve services. We found patients werestill dissatisfied in some aspects of the service.

Although staff told us that they felt able to speak up if theywere concerned, there were no comments from staff to theinspection team about the problems of responding to callbells in time, or having time to provide emotional supportto patients. Staff raised concerns regarding the level of carethey were able to provide by completing incident reportsbut it was not clear to staff that these were acted upon.

Surgery

Surgery


Vision and strategy for this service• Staff in the surgical service were aware of the trust

campaigns to ensure staff provided individualised careto patients and visitors. Staff in wards were aware of thevision to provide ‘better healthcare’ for the localpopulation.

• Theatre staff we spoke with in focus groups told us thatthey were aware of the ‘Stop the Line’ initiative. Theyhad used the process successfully to protect a patientand this had given them confidence they would besupported. Theatre staff knew of plans for upgrading ofoperating theatres, they told us about investmentalready made to renew equipment, and were aware ofcontinued move towards day surgery and keyholesurgery. They told us of intentions to provide localservices where possible in the Trust and of the specialistsurgeons that had joined the Trust.

Governance, risk management and qualitymeasurement• We found that there was a lack of action taken by

managers to address known issues. An example of thiswas in respect of medication omissions whichcontinued to be reported but little or no actin was takenby managers to address these.

• Although the ward managers had audited care records,the process had not identified weaknesses in riskassessments and the plans of care that we identifiedduring the inspection. This meant that audit processeshad been ineffective in improving the care records topromote better care.

• We observed in operating theatres that there was goodlocal leadership and flexibility of working to maintainsafety. Where a patient had arrived late, the anaesthetistand surgeon agreed to have a mini briefing for that caseprior to the procedure later in the session.

• In operating theatres, we saw that staff were supportedby managers to focus on key areas of performance thatmaintained patient safety.

• Risk registers included an item about the environmentin operating theatres which affected the ease ofcleaning of some surfaces. There was a capital plan inplace to improve the relevant parts of the premises.

Leadership of service• ‘Stop the Line’ had been effectively used at team level in

operating theatres. they felt assured that managers hadresponded appropriately to their request.

• In operating theatres, the absence levels of staff hadbeen reduced by 50% in the year prior to our visit. Thiswas due to clear monitoring, and support for staff, incollaboration with personnel and occupational healthstaff. Flexible contracts had been implemented whereappropriate, to enable staff to continue in service.

• There was a new appraisals system in place whichmeant that rates of completion were 70% in operatingtheatres. It had been 85% before the new system.Managers said they were working on ensuring all staffwere appraised using the new system.

Culture within the service• Medical staff in surgical services told us they were well

supported by seniors and considered it was a goodworking environment.

• Nursing staff told us they felt supported by theirmanagers. They said they felt able to speak openly ifthey had a concern. There were clear problems raised bypatients with inspectors, but there were no incidentsreported that staff had raised concerns regarding thelevel of care they were able to provide.

• Staff in operating theatres stated they felt it was asupportive work environment; they were encouraged toattend training and felt they could raise issues in theteam or during procedures if required.

Public and staff engagement• Data showed that patients on Juniper Ward were more

willing than those in other areas to provide feedback ontheir experiences. The feedback from Juniper ward alsoshowed that in March, May and June they weresignificantly less likely to recommend the service tofriends and family. In our inspection we found manypatients in this ward were dissatisfied with the care theyhad received.

• Although there was clear evidence that patients wereunhappy with the service on Juniper ward, it was notclear how staff of the ward or trust managers intendedto tackle the issues of missed medication, pooremotional support and lack of continuity of care. Thismeant that managers had not responded to recentnegative patient feedback and information thatindicated the problems that could be leading to patientdissatisfaction at the time of our inspection.

• Staff had been involved by the trust in developing theoverall strategy. Two staff said they had attendedworkshop to discuss the ‘better healthcare’ plans.

Surgery

Surgery


Innovation, improvement and sustainability• A survey in operating theatres, used to gather views of

patients about anxiety and feelings through theprocedure, had led to improvement in service. As aresult of feedback, more time was allowed for patientsto talk with the anaesthetist or surgeon in theperioperative period.

• The team in the pre-assessment department wereproviding a flexible and responsive service, andcontinuing to develop ways to enable easier access forpatients. They told us they were planning provision ofthe service in rural areas, such as Doddington, to bemore convenient for patients from that area.

Surgery

Surgery


Safe Good –––

Effective Good –––

Caring Good –––


Well-led Good –––

Overall Good –––

Information about the serviceThe Critical Care Centre at Hinchingbrooke Hospital hasnine beds. The centre provides both level 3 care, that is forpatients requiring one-to-one support, such as thoserequiring artificial ventilation, and level 2 and level 1 bedsfor high dependency care. Designated staff in the teamhave an additional role as an outreach specialist across thesite. This is to manage the care for patients that have adeterioration of their condition. The critical care service hasfour consultants, providing cover 24 hours a day, sevendays a week.

As part of our inspection we spoke with two consultantmedical staff, seven registered nurses, including a clinicaleducator, pharmacist, resuscitation officer and the leadnurse for the Critical Care Centre. We spoke with threepatients and two relatives. We observed the care andtreatment patients were receiving, and viewed five sets ofcare records.

Summary of findingsCritical care services were good overall. We found thatservices were safe, as competent medical, nursing andother professionals worked effectively together toensure safety. The environment was cramped and old,which meant that staff had to work flexibly andefficiently to ensure cleanliness, safety, and privacy anddignity for patients. The service is effective as stafffollowed clinical guidance and locally agreed protocols.Performance data showed that there were few incidentsof harm.

The service was caring as patients and relatives told usthat staff were very supportive. There were systemsavailable to provide follow-up emotional support ifrequired. Critical care services were responsive becausea range of detailed assessment records were used toprompt staff to meet patients' individual needs.Children were cared for in the Critical Care Centre, butthis was a temporary measure to provide urgent supportuntil specialist care was arranged. The service waswell-led, as staff worked well as an integrated team toprovide very specialist care within the unit, and also topatients requiring aspects of intensive care in otherward areas. Audit work was established by the outreachstaff to monitor the overall management ofdeteriorating patients in all wards.

Criticalcare

Critical care


Are critical care services safe?

Good –––

Critical care services were safe. This was because staffmanaged the use of the space, maintained cleanliness andorder, and followed procedures to prevent cross-infection.Medical and nursing staff levels were maintained at safelevels, although the cover across to the aligned coronarycare unit meant that cardiology staff were needed tosupport at times to maintain safe medical cover. We sawthat nursing staff were flexible in managing peaks inworkload. Contingency arrangements were in place if safestaffing levels were not able to be maintained.

We found that patients care was risk assessed, monitoredand provided in a safe environment. Safety thermometerdata showed that there were few incidents of actual harmto patients from the care they received and this togetherwith the outcomes in the ICNARC report providedreassurance that patients had not suffered harm.

Incidents• Medical and nursing staff told us that they were aware of

how to report incidents. There was a culture in the teamthat risks were raised and managed. There had been areview of the infection control concerns related to theenvironment which had led to a capital plan tocommission a new critical care department.

• If children were admitted to the Critical CareCentre(CCC) this was reported as an incident for review,as there were risks in caring for children in the adultcritical care unit due to the relative inexperience of staffwho were not routinely caring for sick children. Therewere clear arrangements with Addenbrookes Hospitalspaediatric service for advice or to transfer children whenthis would be the safest option.

• The most frequently reported incidents were delayeddischarges to ward areas due to bed occupancypressures in the hospital.

• Staff had reviewed reports about insulin medicationerrors. In analysis these had been shown to be clinicaljudgement about changes made to prescriptions.Raising the issue through incident reporting had led todiscussion with physicians and clear protocols beingestablished for changes to insulin prescriptions.

Safety thermometer• The Safety Thermometer information for May 2013 to

May 2014 showed no falls reported, and a small numberof pressure ulcers reported in the past year. There werefive avoidable pressure ulcers reported from the CCC inthe 15 months prior to our visit. Staff used a detailedcare bundle to assess and monitor skin integrity

• Safety Thermometer data showed there had been twocatheter infections reported between March 2014 andMay 2014. These were patients that had been admittedto the unit with infections. We saw that care bundlechecks were in place for patients with urinary catheters.

• There were no reports of MRSA or C.difficile infections inthe critical care centre.

Cleanliness, infection control and hygiene• The environment of the unit was assessed by the trust

as requiring upgrading to meet infection controlstandards. A new department was in construction, andthe older unit, which was in use at the time of our visit,was to be decommissioned early in 2015. We saw thatcleaning procedures and staff practices meant thatinfection risk was managed. Staff observed goodhand-washing technique, and used personal protectiveequipment appropriately to prevent the transfer ofinfection.

• Intensive Care National Audit and Research Centre(ICNARC) infection control data showed that there wasno issue with infection prevention and control. In June2014 the critical care areas achieved 100% compliancewith hand washing audits. This had been the same forthe previous two months.

Environment and equipment• There was equipment easily available for intubation and

intravenous access. There was bedside equipmentavailable for rapid access if required. Resuscitationequipment was readily available, and we saw this hadbeen checked routinely, including defibrillator padsbeing in place ready for use.

• Equipment was visibly clean and clearly labelled readyfor use. We saw that electrical testing labels were withindate for equipment on the unit.

• There were two kidney support machines available,which staff told us were regularly used. A third machinehad been leased during our inspection visit due topatient needs.

Criticalcare

Critical care


Medicines• We saw that the stock check of medications in the

controlled drug cupboard had been signed for aschecked daily. Medications for resuscitation werechecked daily with the emergency equipment.

• A pharmacist was included in the daily multidisciplinaryteam discussions, which meant that expert advice wasavailable to the team, including medicationinteractions, dosages and route of administration.

• In May 2014 there had been nine medication errors andin June 2014 there had been three errors reported.Analysis of the reports had showed the decisions bynursing staff was to maintain clinical safety where therehad been unexpected changes in prescriptions. This hadbeen led to improved protocols for insulin prescribing.

Records• Risk assessments were completed in care records. We

found that documents were fit-for-purpose andcompleted accurately. We saw that assessment recordswere completed appropriately, and also providedprompts to staff to follow local protocols andevidence-based care.

• There were appropriate detailed records made for eachpatient daily of the care bundles checks andobservations, including ventilator checks. Staff alsorecorded their checks on blood results, sepsis actionssuch as blood cultures or swabs, and sedation rates.

Safeguarding• Staff told us that they were aware of the procedure to be

followed to report any cases of suspected abuse ofvulnerable adults or children.

• Only 79% of staff had received training in adultsafeguarding but 93% had attended safeguardingchildren training (June 2014). The trust acknowledgedthat there were problems with safeguarding training andhad a lead nurse who was undertaking this.

Mandatory training• We saw that mandatory training had been 98%

completed by the staff in the Critical Care Centre. Staff inthe critical care team had also completed a range oftraining in competencies and certificates, such as for thecare of the critically ill child.

• There was a part time nurse clinical educator employedin the team who spent time supporting staff, supervisingin practice and providing training sessions specific tocritical care.

Management of deteriorating patients• We observed care in the unit, and reviewed

documentation. We saw that patients were wellmanaged. We saw that documentation was designed toguide staff in the assessment of patients and planning ofdischarge.

• Staff made very detailed assessments of patient’s needsand risks to their health and welfare. This included datacollection related to infection, skin integrity andnutritional status. Records were available to promptstaff in managing patients admitted with learningdisabilities.

• There were separate staff in the unit who provided anoutreach service, supporting critically ill patients inother ward areas to reduce the likelihood of admissionto the Critical Care Centre, or co-ordinating admission tothe centre where required. This was a service providedseven days from 8am to 8pm.

• The specialist outreach staff in the centre haddeveloped a policy for the use of early warning scoresand the management of deteriorating patients. This waspart of the service provided to the ward areas. Theservice included undertaking audits of the use of earlywarning scores and providing feedback to ward teams.

• Escalation and management of deteriorating patients inthe critical care unit was through close monitoring andmanagement of all critically ill patients. The nursing staffand junior medical staff had clear routes to escalate tothe consultant staff for the unit.

Nursing staffing• We checked staffing levels against recommendations of

The Intensive Care Society Core Standards 2013. Wefound that there were appropriate levels of staff. Thereare five level 3 beds and four level 2/1 beds. These bedsare used flexibly depending on patient need. Three ofthese beds are nominally coronary care beds. Theexpected number of staff per shift is six registerednurses and one healthcare assistant on a day shift andfive registered nurses and one healthcare assistant on anight shift. At times when coronary care patients werealso in the unit the staff levels could be approachingcapacity. On the second day of our visit this was the casefor the morning shift but additional staff were scheduledfor the afternoon, the following three nights and days toensure safety. The matron for the unit and clinicaleducator were not counted in the nurse staffing and so

Criticalcare

Critical care


initial contingency for increased patient dependencycould be covered by these staff undertaking clinicalduties. We observed this was the case on the secondday of our visit.

• At times when the safe capacity was likely to beexceeded the contingency arrangement of non clinicaltransfer to another critical care centre would be put intoaction.

• There was a good skill mix on the unit, with 60% of staffbeing specialist trained registered nursing staff. Therewas a matron on the team, and a part-time clinicaleducator which was a good ratio for the number of staffemployed.

• Staff told us that it was difficult to secure the services ofspecialist agency staff if they needed to supplementstaff levels, for example, due to sickness.

Medical staffing• The service was covered by four intensive care

consultants. Consultant anaesthetist cover was 24 hoursa day, seven days a week. Cover was maintained andsupported by cardiologists when coronary care patientswere in any of the three allocated beds.

• There was medical cover for the coronary care bedssituated alongside the unit, including cardiology input.There were no medical staff trainees in the unit, butescalation of problems from the FY1 doctor waseffective.

• Intensive care medical staff took responsibility formanagement of coronary care patients in the alignedunit at times. Cardiologists were available to supportwhen both units were full, and the pace of work wasvery heavy to cover medical reviews and managementacross both areas.

Major incident awareness and training• Staff were aware of the major incident plan for the trust.

This was available on the trust intranet. We found thatthe policy document was up to date but there wasinsufficient detail to guide CCC staff during an incident.There were no ready printed action cards for individualsin the critical care unit to follow in an incident. Thepolicy had only limited information to advise staff in theCCC what action to take in case of major incident. Stafftold us about the training events which were commonfor all staff in the trust, but this training did not include

any specific guidance for CCC staff. The CCC could be anessential part of the major incident response for thetrust but it was not clear how this facility would beprepared to manage critically ill patients.

• There were training events which were common for allstaff in the trust.

Are critical care services effective?

Good –––

Critical care services were effective. Audits showed thatpatients were more likely to have better outcomes withinthe critical care centre than other areas of a similar size.However audits also showed that the level of dependencyof patients admitted was lower than other units of a similarsize. We saw good multidisciplinary working, using clearguidance and protocols, which led to good outcomes forpatients. Some patients had longer admissions in thecentre than required, due to limited bed availability onother wards.However, longer stays in the centre couldmean that patients took longer to return to their usual levelof mobility and independence.

Evidence-based care and treatment• The Critical Care Centre submitted data for national

audit and performance review, such as SafetyThermometer and Intensive Care National Audit andResearch Centre (ICNARC) reports.

• Staff had developed policies for different types ofventilator support for patient’s breathing, both in theCritical Care Centre or in other ward areas.

• We saw that care bundles were used to ensure effectiveassessment of risk for ventilated patients, tracheostomy,central venous and peripheral infusion sites, urinarycatheters and skin care. Documentation showed thatstaff checked these care requirements twice each day topromote safety and reduce the likelihood of infection.

• When children were admitted to the Critical Care Centre,the care was provided in close collaboration with thespecialist paediatric service, which would then rapidlyhave taken over the care as the child was transferred toa specialist children’s intensive care unit.

Pain relief• Staff kept close monitoring on sedation rates for level 2

and 3 patients who were under the care of theanaesthetists.

Criticalcare

Critical care


• The pain specialist nurse was available as required tosupport patients post-operatively in all ward areas.

Nutrition and hydration• Critical care included detailed management of patient’s

nutrition and hydration, dependent on the needs of thepatient. Pharmacy staff supported decision-makingabout route of administration of medications. Dailychecklists included checking the cleanliness andintegrity of feeding lines and equipment.

• Patients were given detailed advice, for after the criticalphase of their illness, to promote recovery.

• Staff told us that support for kidney function was usedregularly as part of the care provided to critically illpatients.

Patient outcomes• Latest ICNARC data shows that most patients admitted

to the unit were level 2 patients although a quarter werelevel 3 requiring the most support from the critical careteam.

• ICNARC and APACHE II data both show that mortality inthe unit is below the national average meaning thatpatients survive better at Hinchingbrooke Hospital.

• The average length of stay for a patient in the criticalcare centre was around 5 days but there were generallyhigher number of delayed discharges when comparedto similar units.

• In recent months there had been no unit acquiredinfections which meant that patients could expectbetter outcomes.

Competent staff• We spoke with the clinical educator, who told us that

57% of staff had had their appraisal in the last year, butthis is in the context of a new appraisal system. Allappraisals had been completed in the previous year.

• Staff had packages of training and checks to follow, toevidence their competence with technical skills requiredin their role.

• Staff were able to access specialist training thoughAnglia Ruskin University, and shared with otherhospitals in the area.

Multidisciplinary working• The availability of the microbiology service was limited

at the time of our visit. Due to staff leaving themicrobiology service was provided by locum cover atthe time of our inspection. This meant that there had

been no microbiologist on multidisciplinary discussionsand patient planning, and no visits to the unit bymicrobiologist to review practices and advise on sepsisissues.

• Pharmacy staff supported team discussions aboutappropriate medication for patients in the centre. Thepharmacist provided advice and checks oncompatibilities of drugs including reviewing overallmedication treatment. In addition the staff used theadvice of an antibiotic specialist pharmacist.

• The staff in the unit also provided an outreach service.The service was delivered to high standards and usedcurrent guidelines.

• The trust resuscitation officer was based in the CriticalCare Division and pain control specialist nursesupported when needed for post-operative patients

Seven-day services• The outreach service was provided seven days per

week, from 8am to 8pm.• Staff told us that consultants were available to support

the care of patients at all times.• The service was able to order X-ray imaging out of hours,

but this could be delayed as there was only oneradiographer available out of hours for the hospital site.Staff did not give this as a current problem.

Are critical care services caring?

Good –––

The service was caring. Patients and relatives told us thatthey were cared for with compassion and dignity. Theservice had a follow-up clinic, at which patients wereoffered a range of support to help them rehabilitatefollowing the trauma of needing intensive medical care.

Compassionate care• We saw that care was provided in a compassionate way

in the approach to patients and relatives.• We observed that although there was limited space in

the Critical Care Centre, staff were careful to preservethe patient’s dignity and privacy as much as possible.

• Two relatives told us that they had been very anxiouswhen the patient had been in accident and emergencyand the admission unit, but felt relaxed and well

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Critical care


supported when the patient was in the Critical CareCentre. They said that staff had provided goodinformation, had been very caring, and the facilitieswere excellent for caring for the patient.

Patient understanding and involvement• Patients told us that care in the critical care unit was

very good. They said there was good informationprovided about the service and about their condition.

• We observed staff working very closely with familymembers and patients on admission, explaining thecare processes and allowing them time to askquestions. Patients and relatives told us they felt verywell supported in the unit compared to their anxietywhen passing through other departments and wardsprior to admission onto the CCC.

Emotional support• There was open visiting to the unit for relatives, to

promote continued communication with relatives andpatient although critically ill.

• Patients who had a prolonged admission to the CriticalCare Centre were offered a rehabilitation serviceprovided by a consultant and nurse. The clinicsprovided follow-up support to patients after discharge,and this included support for emotional needs aftercritical care or traumatic experience. This was awell-established and comprehensive package ofsupport. Feedback from patients was posted in the unitfor staff to view. Staff had taken note that some patientshad been disturbed by the general level of noise in theunit.

Are critical care services responsive?

Good –––

The unit was responsive to patients’ needs. Patents incritical care were provided with a comprehensive packageof care following a detailed assessment of needs. Childrenwere cared for in urgent situations prior to transfer to aspecialist service.

Service planning and delivery to meet the needs oflocal people• We found that the staff of the critical care centre were

flexible in managing the patients requiring thisadditional intensive care. When cardiology patients

were in the three allocated beds there was additionalsupport used from cardiology medical staff. In additionthe nursing staff could be supported by the matron andclinical educator if required. We saw on the day of ourvisit that another manager with clinical background inintensive care was also supporting for a short period.

• The unit had nine open critical care beds. BetweenJanuary and March 2014 the average bed occupancyrate for adult critical care beds in HinchingbrookeHospital was 98%.

• We saw that training in the unit provided by the clinicaleducator had included discussion about mentalcapacity and supporting vulnerable patients andfamilies through an admission to the critical care centre.

Access and flow• Admission to the unit was predominantly an unplanned

event from the other ward areas or emergencyadmission. Over half the patients did not receive a visitby the critical care team prior to admission to the unit.Around a third of patients were seen by the outreachteam prior to being admitted to the critical care centre.Patients from ward areas that had deteriorated wereseen by the outreach nursing team or medical staff fromthe critical care centre.

• The problems of discharge from the unit meant thatsome patients stayed for longer than would be usual onan intensive care unit. This was due to the pressure onbeds throughout the hospital. This meant that patientswho were ready to be moved to a normal ward area hadto stay in the Critical Care Centre. In view of the crampedenvironment and lack of toilet or shower facilities, theunit was not appropriate for continued rehabilitationonce the patients had recovered from a critical phase ofillness. This meant that patients who had recoveredsufficiently to be able to use a bathroom continued tohave washes and use a commode by the bedside. Thiscould delay rehabilitation and recovery.

• The limited space and lack of toilet facilities meant thatmovement of patients through the unit, and using thecommode, could result in patient’s privacy and dignitybeing difficult to protect. There were three side roomswith all other bed spaces being in line of sight of eachother. This promotes a high level of observation by allstaff. We saw that staff made efforts to protect dignity byusing curtains as needed and respecting privacy whencurtains were drawn.

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Critical care


Meeting people’s individual needs• The outreach service was provided seven days per week

from 8am to 8pm. This meant that patients withcomplex needs could be reviewed rapidly, and assessedfor management in the ward, or admission to the CriticalCare Centre if required.

• The Critical Care Centre provided care for children. Thiswas usually for a short period until paediatric care couldbe arranged at a more specialist unit. Staff told us that itwas unusual to care for a sick child for more than eighthours. In such cases, a paediatric-trained consultantand nursing staff would be in attendance. We saw thatstaff had all been trained in advanced paediatric lifesupport and related qualifications.

• The service provided follow up to patients to supportrehabilitation after being in intensive care.

• To support patient’s recovery after discharge they wereprovided with a detailed booklet, with a wide range ofinformation to help understand the effects on them ofbeing in intensive care. The booklet included advice onexercise, nutrition and sleep pattern or mood changes.

Learning from complaints and concerns• The views of patients were used to discuss patient

stories and inform future practice on the unit.• We saw that there were very few complaints. Staff

actively sought the views of patients. We observed staffdiscussing care with family members and patients onadmission. We spoke with family members after this andfound they felt able to ask questions about the service.

Are critical care services well-led?

Good –––

The service was well-led because there were clear workingarrangements that promoted consistent provision of care.There was a strong multidisciplinary approach to theservice, and staff told us they were valued as part of thework of the team.

Vision and strategy for this service• The future of the unit, when in the new build facility, was

not clearly described.Staff we spoke with were unawareof the plans for the unit. The trust stated that were plans

for ten beds in the new unit. New cardiology consultantswere considering plans to place cardiology beds inother ward areas which would reduce the dependencyon the intensive care service.

Governance, risk management and qualitymeasurement• Key performance indicators were discussed in the unit

by the clinical lead, head of nursing and businessmanager. The key issues were reported through to theintegrated governance committee. We heard discussionat the meeting about the issues that critical care centrewere having discharging patients back to the wardareas. However the clinical lead did not receive supportfrom this panel in undertaking any action to resolve thisissue.

• The combined theatre and critical care risk register hadonly one item on it relating to critical care areas. Thisrelated to the availability of an anaesthetist to attendany cardiac arrests in the hospital. Whilst action hadbeen identified to be taken the review of this risk was setfor June 2015.

• ICNARC data was collected and submitted in a timelymanner. This showed that the outcomes for patients onthe critical care centre were positive.

• Safety Thermometer data was used to enhanceoutcomes and improve the quality of care for patientsadmitted to the critical care centre.

• Staff said they had not used the ‘stop the line’ processbut that in the specialist unit they raised issues anddiscussed clinical decisions as part of their professionalrole in managing critically ill patients whose conditioncould change rapidly.

Leadership of service• There was a consultant lead from the unit on the trust

board. This meant close links between clinical activity,and the executive group who managed strategicplanning, for the trust overall, and the intensive careservice specifically.

• The care for critically ill patients was a networkarrangement of all the clinical professionals involved.We saw that specialist staff were proactive in developingprotocols and monitoring the adherence to agreedguidance.

• We saw that the unit Matron was approachable andcredible with staff including taking clinical duties whenrequired to support staff.

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Critical care


Culture within the service• Staff told us that there was strong multidisciplinary

working in the service, and that they felt they could raiseissues and suggestions when needed. There was goodcollaboration between consultant staff to ensure safemanagement of patients.

• We observed there was a good atmosphere in the unitwith staff providing views openly and discussing patientcare and organisational issues with the Matron andmedical staff.

Public and staff engagement• Staff told us that their views were sought regarding

service planning and development. They said they hadbeen included in the commissioning of the newdepartment.

• We saw that patient feedback from the post dischargeclinic was being recorded on a display board in the CCC.Some patients had commented about noise which hadled to the purchase of quieter pieces of kit such as quietclosing bins.

Innovation, improvement and sustainability• There was a potential risk to sustainability given the

current staffing availability to provide the overallconsultant, medical and nursing cover when the newfacility was opened.

• Medical staff told us that it was their intention that in thedevelopment of the new critical care unit in early 2015there would also be some mointored beds allocatedwithin other ward areas. This would clarify the role forthe critical care service in the new build facility. Theseplans were not finalised yet.

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Critical care


Safe Good –––

Effective Good –––





Information about the serviceThe maternity service at Hinchingbrooke Hospital includesbirths at home, and births at the hospital, offering bothhigh risk (consultant-led) and low risk (midwife-led)packages of care to women. The hospital managed 3,218hospital births and 96 home births since April 2013.

The inspection team included one inspector, a specialistmidwife nurse adviser and a consultant obstetricianadviser. During our inspection; we spoke with 41 staff,seven patients and three partners. We visited the antenataland postnatal wards, early pregnancy and day assessmentunit, gynaecology and labour wards. We receivedcomments from our listening events, and from people whocontacted us to tell us about their experiences. We usedinformation provided by the organisation and informationthat we requested, which included feedback from youngpeople and women using the service about theirexperiences.

Summary of findingsThe current level of maternity services provided towomen and babies by Hinchingbrooke Hospital weregood. The maternity unit provided safe staffing levelsand skill mix, and encouraged proactive teamwork tosupport a safe environment. We saw that there werearrangements in place to implement good practice,learning from any untoward incidents, and an openculture to encourage a focus on patient safety and riskmanagement practices.The trust is working towardsachievement of Level 2 Unicef's Baby Friendly Initiative

All permanent staff were appropriately qualified andcompetent to carry out their roles safely and effectivelyin line with best practice. There were detailed and timelymultidisciplinary team discussions and handovers, toensure women and babies care and treatment wasco-ordinated and the expected outcomes wereachieved. Staff in all roles put effort into treating womenwith dignity, and most women felt well-cared for as aresult. Staff in the hospital and community were flexiblein working practices and responding to the needs ofwomen and babies. We found the midwifery leadershipmodel encouraged co-operative, supportiverelationships among staff. Staff reported that themanagers and supervisors ensured that they feltrespected, valued, supported and cared for. Staffcontributions and performance were recognised andcelebrated.


Maternity and gynaecology


Are maternity and gynaecology servicessafe?

Good –––

The current safety of maternity service provided to womenand babies by Hinchingbrooke Hospital was good. Thetrust provided safe staffing levels and skill mix, andencouraged proactive teamwork to support a safeenvironment.

There were arrangements in place to implement goodpractice, learning from any untoward incidents, and anopen culture to encourage a strong focus on patient safetyand risk management practices. Staff had identified thethings that were most important to delivering safe care intheir area, and had established standard operatingprocedures that reflected national and professionalguidance.

Incidents• We looked at incident reporting policies, a database

which included maternity incidents raised by staff, andsafety meeting minutes, and found that there werearrangements in place for reporting patient/staff safetyincidents and allegations of abuse, which were in linewith national guidance.

• We found maternity services current incident reportingsystem was part paper-based and part electronic, andseparate from the rest of the organisation. We wereadvised that the reporting system was being upgradedto Datix in the near future, to ensure a consistent,effective approach across the trust.

• There were 897 maternity incidents reported in the lastyear. The five top incidents were shared with staff andaction plans to reduce the risk of reoccurrence werehighlighted in the clinical risk management bulletin July2014 such as :an increase in sampling incidentsresulting in fail safe clerks employed to monitor, reportand action sample issues also increased monitoring andcase reviews due to the numbers of unexpectedadmissions to special baby care unit (SCBU)..

• We saw minutes from the Monthly Perinatal MortalityMeetings which showed discussions and case reviews bymulti-disciplinary teams to consider any changes topractice to improve outcomes for patients.

Safety thermometer• The maternity unit was open in their reporting practices.

We saw the clinical performance dashboards forobstetrics such as Venous Thrombosis Screening (VTE),numbers and types of births, 3rd and 4th degree tears,post-partum haemorrhage (PPH) and sepsis numberswere reported. We saw that the VTE quality assessmentreports June 2014 were satisfactory. Clinical riskmanagement bulletins were also displayed for staffreference, and key performance indicators, such asinfection control practices were on the informationboards for the public. The risk lead midwife could showactions being taken where results were outside of thestandard such as increased PPH numbers wherequarterly audits and increased staff education werehighlighted to ensure early recognition and appropriatemanagement of the mother.

• We saw staff had access to guidelines and riskmanagement meeting minutes on the intranet and thehead of midwifery noted weekly senior clinical meetingswere actioned to review all adverse deliveries andupdate staff to ensure appropriate practice changeswere implemented where required.

• There was a programme of risk based audit carried outto monitor adherence with the standard operatingprocedures. We saw that action was taken as a result offindings, such as “inadequate information for formulafeeding mothers”- Action for staff to note it is mandatorythat mothers have 1-1 discussion/demonstration

Cleanliness, infection control and hygiene• We found no concerns during the inspection of the

maternity unit. Ward areas appeared clean and we sawstaff regularly wash their hands and use hand gelbetween patients. 'Bare below the elbows' and isolationpolicies were adhered to. A recent hand hygiene auditscored 100%, and 'I am clean stickers' were onequipment.

• We looked at a recent reported infection outbreak, andnoted appropriate actions taken to safeguard patients.There was good staff awareness regarding practicesimplemented to manage the situation recorded in riskbulletins and risk registers.

• Hand hygiene audits showed that the unit was awarded100% for hand washing.




Environment and equipment• There were adequate storage facilities and levels of

equipment for safe monitoring of women and theirbabies.

• Resuscitation equipment was in line with nationalguidance and checked regularly. We raised with theprovider concerns regarding the distance of theresuscitation trolleys to some key clinical areas. Thetrust confirmed that it had undertaken time tests andthat all trolleys were accessible within three minutes.

Medicines• Staff we spoke with were aware of medicine

management policies for reference purposes, andmonitoring systems were in place to pick up medicationerrors.

• We saw that locked drugs cabinets were in place forcontrolled drugs, we noted that some intravenous fluidswere stored in unlocked cupboards, and we reportedthis to the trust at the time. The trust reported that theywere awaiting delivery of digital locks and have replacedall locks with digital lock to ensure security of theseareas. The trust states that these are now in place.

Records• The record system included the use of

nationally-recognised medical records, which was notedas good practice.

• Maternity Notes were reviewed, and we found theyincluded physical risk assessments, which werecompleted to safeguard patients.

• We saw that records were handled safely to supportdata protection practices.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards• We saw good consent practices in line with national

Royal College of Obstetricians and Gynaecologists(RCOG) guidelines. Patients told us that they were wellinformed regarding the risks, such as for electivecaesarean sections and the use of epidurals. Partnerstold us that they felt involved where necessary in thedecision-making process.

• We noted that Mental Capacity Act and Deprivation ofLiberty Safeguards (DOLS) awareness was currently notincluded in the Trust induction or mandatory trainingprogramme for clinical staff although some midwivessaid they had received awareness training in capacitymanagement

• It was reported that there was a vulnerable women'slead midwife who worked closely with the mental healthteams to pick up mental capacity issues. We saw a list ofvulnerable women highlighted for additional support inthe clinical office for staff reference.

Safeguarding• We found that the trust identified the things that were

most important to protect people from abuse and topromote safety. There were effective safeguardingpolicies and procedures on the intranet for staffreference, which staff we spoke with were fully aware ofand could explain the reporting process where concernswere raised.

• The training records showed that appropriatesafeguarding training was being provided. The providerhad a flagging system to show when staff were due forrefreshers, and there was current compliance with trustpolicy at 86%.

Mandatory training• Mandatory training was regularly monitored, with

triggers in place to pick up non-attendees. The currentlevels were 85%, and staff noted the content wasappropriate.

Management of deteriorating patients• Staff knew how to activate escalation processes, which

work well; for example, drafting in additional staff tocover increasing levels of demand, or responding towarning signs of rapid deterioration of patients.

• The maternity department knew how to escalateconcerns about women having difficult labour andfigures confirmed that the number of interpartumtransfers out of the unit was within accepted limits.

• All staff knew what to do in an emergency situation, andpraised the introduction of blue (need for paediatrician)and yellow (paediatrician not required) emergencycodes, to ensure that the right people were present tosupport where needed, which increased the confidenceof the team.

Midwifery staffing• Midwife to birth ratio is 1 to 28 births; when

management and specialist midwives are included thisrate improves further to 1 to 25 births. Staff gaveexamples of increased staff numbers when demand washigh, such as calling community midwives into thehospital, and that managers were responsive to




changing needs and circumstances, such as cover forlong-term sick leave or study leave. There were on-callcommunity midwives for home births, and emergencycare each night.

• Ratio of supervisor of midwives to midwives was 1-15,which meets the national standard.

• We saw that midwifery staff were confident thatmanagers ensured the right staffing levels and skill-mixacross all clinical and non-clinical functions. Managerstold us that currently there was a high level of maternityleave amongst staff, which continued to impact onmidwifery services. The midwifery-led birthing unit doesnot currently have a dedicated team because of this.

• We saw staffing levels displayed for patient reference,which was good practice. Most patients we spoke withwere very positive about the approach to safe care onthe unit.

Medical staffing• Doctors we spoke with noted that the right medical

staffing levels and skill-mix across all clinical disciplineswere sustained at all times of day and week, to supportsafe, effective patient care and levels of staff wellbeing.There was 60 hours consultant cover, with full on-callsupport out of hours and at weekends. We saw that themedical staffing for the unit was appropriate for thecurrent levels of activity.

Are maternity and gynaecology serviceseffective?

Good –––

There was good evidence of research and an ethos ofshared learning. National guidance was beingimplemented, and monitoring systems to measureperformance were in place. Care was consistently deliveredin line with evidence-based, best practice guidance andprofessional standards. Patient outcomes were withinnormal parameters; there were no outliers raised in thedata packs when benchmarking against other trustsnationally.

All permanent staff were appropriately qualified andcompetent to carry out their roles safely and effectively inline with best practice; we saw good examples ofsuccession planning to develop staff. The number of staffreceiving continual professional development and clinical

supervision was satisfactory; the appraisal rates wereimproving. There were detailed and timelymultidisciplinary team discussions and handovers, toensure patients’ care and treatment was co-ordinated, andthe expected outcomes were achieved. There was goodcollaborative working with partners and other agencies.

Evidence-based care and treatment• The provider had funded posts for a research lead

midwife and practice development midwife. Auditoutcomes were presented regularly through the clinicalrisk management bulletin for practice developmentssuch as: Bereavement Services in maternity servicesSANDS which indicated the need for additionalmultidisciplinary staff training. Another example wasSupplements given in clinical practice-Baby friendlyinitiative which highlighted limited uptake in antenatalhand expressing.

• Staff showed us that there was a process for identifyingrelevant legislation, current and new best practice, andevidence-based guidelines and standards, in line withRoyal College of Obstetricians and Gynaecologists(RCOG) guidelines (including Safer Childbirth: minimumstandards for the organisation and delivery of care inlabour). These were then reviewed and approvedthrough appropriate channels before beingimplemented.

• We spoke with one doctor who had recently become theStrategic Clinical Network Lead for high risk obstetriccare within the Eastern Clinical Research Network (CRN:Eastern), and will lead the development of CRN: Easternclinical activity within this specialty; to encourage localclinicians across the region to participate in clinicalresearch network portfolio studies, build upon localclinical strengths, and research interests and priorities,which was noted as good practice.

• Staff had identified the things that were most importantto delivering safe care in their area, and had establishedstandard operating procedures that reflect national andprofessional guidance, which included, infection controlpractices, information management and World HealthOrganization checklists, amongst others.

Pain relief• A range of options were available to help patients cope

with pain, ranging from self-administered entonox, to a24-hour epidural service. Patients told us that their painwas managed well.




Patient outcomes• There was strong evidence of local and national audit

activity, with staff reporting tools such as risk bulletins,and risk and integrated governance meeting minutes onpractice changes to improve outcomes for patients. Staffwe spoke with were well informed on evidence-basedcare and new treatments, such as the introduction ofcomplementary therapies to help stimulate labour andreduce anxiety in post-date patients.

• The trust had a better than the England average numberof caesarean section births at 7%. The national averageis 10%. Emergency caesarean section rates were alsolower at 12% rather than 14% nationally. This meantthat more women were able to give birth naturally.

• Readmissions to the maternity and neonatal units andthe rate of Puerperal sepsis and other puerperalinfections were within normal parameters; there wereno outliers raised in the data packs when benchmarkingagainst other trusts nationally. Outcomes were clearlydisplayed on the electronic ward boards, such as thenumber of natural births and caesarean sectionsmonthly.

• There was ongoing monitoring of the top risks, such asthird and fourth degree tears and post-partumhaemorrhage; and support was provided from thesupervisors of midwives regarding practicedevelopments to improve outcomes for patients.

• Breastfeeding initiation rates were 82%, although thisdropped below national levels to 55% in August 2014 atdischarge. Additional initiatives were being encouragedto improve this.

Competent staff• Staff told us that no agency staff were used currently

and the bank is made up of trust staff. All permanentstaff were appropriately qualified and competent tocarry out their roles safely and effectively in line withbest practice. Staff told us that there were effectiveinduction programmes, not just focused on mandatorytraining, for all staff, including students and midwiferycare assistants. We were shown competency-basedassessments, which all midwives are required tocomplete. We looked at the annual maternity two dayupdate programmes, which included updates inservice-specific care, such as infant feeding, and care ofdiabetes, and noted that the current rate of attendance

was 93% of midwives and 84% of doctors. Specialistlead posts were actively encouraged, such as specialistmidwives caring for women with gestational diabetesand providing breastfeeding support.

• The provider had mechanisms in place to ensureappropriate levels of supervision and appraisal of allstaff, and revalidation of doctors. The appraisal rateacross the division was under target at 63%, as a newsystem was being put in place.

• Students and midwives confirmed that training wasprovided as part of the local induction process, and alsothrough the Acute Deteriorating Patient Course (ADP),life support programmes and patient transfer courses.

Multidisciplinary working• We saw examples of stakeholder events, such as

Cambridgeshire and Peterborough CCG 5 Year Strategy;Children and Maternity Stakeholder Conference in June2014. The event achieved the objectives set, which wereto engage effectively with a wide range of stakeholdersand to put in place a review process across threeregional maternity units to shape future pathways ofcare.

• Staff we spoke with, including community midwives andstudents, were aware of the midwifery strategy and theimportance of joined-up working with health visitors,GPs and school nurses, to support patients carepathway, both in hospital, and back in the community.

• We found by observing ward areas, and listening tofocus groups and individual doctors, midwives, supportworkers and administration staff, that there weredetailed and timely multidisciplinary team discussionsand handovers, to ensure patients’ care and treatmentwere co-ordinated, and the expected outcomesachieved. Care and treatment plans were recorded andcommunicated with all relevant parties to ensurecontinuity of care.

• Doctors and midwives confirmed good workingrelationships with the staff in the special baby care unitwhich is run by Cambridgeshire Community ServicesNHS Trust. Meetings and handovers were patientfocussed and integrated to include smooth transferprocesses.

Are maternity and gynaecology servicescaring?




Good –––

Staff in all roles put effort into treating patients with dignity,and most patients felt well-cared for as a result. Themajority of patients we spoke with, and those close tothem, were encouraged to be involved in their care, treatedas equal partners, listened to and were involved indecision-making at all levels.

There were positive views from a breadth of patients andthose close to them about the care provided, which weresupported by the views of the staff. Care waswomen-centred, and parents sensitively supported wherebereavement occurred. The provider encouraged leadspecialist midwives to develop services, such ascomplementary therapies to induce labour and reduceanxieties.

Compassionate care• The majority of patients told us that staff responded

compassionately to discomfort and emotional distressin a timely and appropriate way. However, we didreceive a significant complaint regarding breastfeedingsupport and staff attitude during the inspection, whichhad been highlighted previously in the maternity survey.The trust is working towards achievement of Level 2Unicef's Baby Friendly Initiative and recent auditsundertaken to support that process have demonstratedgood breast feeding support and staff attitudes.

• There were concerns around the NHS Friends andFamily Test (FFT) returns (numbers) from patients inmaternity. There were action plans to improve this,including more training into FFT for maternity services.However actual scores in all three sections, antenatal,postnatal and birth, were above the England average at76, 76, 84 respectively. Results obtained showed that75-84% of women were extremely likely to recommendthe service, as of July 2014.

• In the 2013 Maternity Survey the hospital scored aboveaverage in the question relating to women being treatedwith dignity and respect. In all other aspects thehospital was rated as average. We saw good examples ofstaff interacting well with patients and partners and thatthere was consideration for privacy and dignityrequirements during the inspection.

Patient understanding and involvement• Patients told us that they were involved in

decision-making, and understood the care andtreatment they received. The vast majority were positiveregarding the professionalism and support provided bythe clinical and non-clinical staff.

• We saw evidence of feeding and antenatal education,the initiation of feeding, and ongoing support forparents. Patients told us that they were offered a tour ofthe facilities prior to birth to help their understandingand involvement.

Emotional support• Patients were aware of 24 hour access to advice from

the midwives, and one-to-one care throughout labour,and we saw there was good chaplaincy support formultiple faiths. One patient admitted for bed restcomplimented the calm caring approach of the staffwho reduced her anxiety on admission.

• There was a bereavement midwife in post, and staffwere familiar with bereavement protocols andcounselling support opportunities for parents whererequired.

Are maternity and gynaecology servicesresponsive?

Good –––

The responsiveness of the maternity service was good.There were good mechanisms for information sharing withexternal commissioners and stakeholders, to provideco-ordinated and integrated pathways of care. Staff in thehospital and community were willing and flexible inworking practices around responding to the needs ofpatients.

People who use the service were asked about theirspiritual, ethnic and cultural needs, and their health goals,as well as their medical and nursing needs. Their care andtreatment was planned and delivered to reflect theseneeds, as appropriate. The provider was open andtransparent about how it had dealt with complaints andconcerns, and the managers were aware and action planswere in place to encourage improvement based on patientfeedback.




Service planning and delivery to meet the needs oflocal people• The delivery unit has 10 dedicated birthing rooms,

including a birthing pool. There are also a variety ofmats, cushions and birthing balls to assist with mobilityand comfort in the early stages of labour.

• We saw, through minutes of meetings and responsesfrom focus groups, that the provider encouragesengagement with commissioners of maternity services,health visitors, school nurses, GPs, relevant groups,people who use services and those close to them, toprovide co-ordinated and integrated pathways of carefor pregnant women.

• Doctors and midwives confirmed good workingrelationships with the staff in the special baby care unit,which is run by Cambridgeshire Community ServicesNHS Trust. Meetings and handovers werepatient-focused and integrated to include smoothtransfer processes. There were service level agreementsin place to support the service, but further developmentwas required, as parts of the current practice relay ongoodwill as opposed to formal undertaking. The trusttold us that the service level agreement with the trustproviding paediatric cover is to be reviewed as workingpractices have altered since its last review two yearsago.

• Open days had been actioned, which included questionsessions with consultants, and tours of the wards toensure women were aware of the services provided inthe maternity unit at Hinchingbrooke Hospital. The unitis currently working towards Unicef's Baby FriendlyInitiative award at level 2, which requires demonstrationthat all staff are educated to the same standard andcontinually audit services to promote and sustainbreastfeeding.

Access and flow• Hinchingbrooke Hospital’s MDAU (Maternity Day

Assessment Unit) is an outpatient assessment area forpregnant women who have antenatal concerns,including reduced foetal movements, raised bloodpressure and/or protein in their urine. We spoke with apregnant woman admitted for monitoring, who wasimpressed with the access and timely admission.

• There was a lead midwife, who worked jointly withhealth visitors and mental health services to ensureappropriate services were available for vulnerable

women. Community midwives we spoke with told usthat services provided in the community were flexibleenough to fit in with people’s lives where possible, suchas work and family commitments.

Meeting people’s individual needs• People who use the service were asked about their

spiritual, ethnic and cultural needs and their healthgoals, as well as their medical and nursing needs. Theircare and treatment was planned and delivered to reflectthese needs, as appropriate. Women told us they wereencouraged to reflect their wishes for birth in the birthplan. A recent initiative was to support partners stayingon the units where requests were made, with theconsent of other patients if in a shared environment.

• Verbal, electronic and written information that enablespatients to understand their care, was available topatients and their relatives in ways that met theircommunication needs. The provider ensured that theneeds and wishes of people with a learning disability, orof people who lack capacity, were assessed andmonitored appropriately. The hospital has a learningdisabilities liaison nurse to support people whilst inhospital, and also in preparation for discharge back intothe community. There were also interpreting servicesavailable.

• The clinic organisation and counselling support forwomen undergoing termination of pregnancy was good.Outpatient care for medical termination of pregnancywas also good; however, where day-case or inpatientcare was required for early pregnancy problems, andmedical or surgical termination above nine weeks, theservice did not always ensure appropriate placement ina planned gynaecology bay to support these patients’needs sensitively. We understand that the provider iscurrently reviewing provision to improve this. Disposalof foetal tissue was in line with national guidance.

• Specialist clinics with lead specialist midwives,including diabetes, foetal medicine, and pre-operativeassessments, were available to support patients.

• A complementary therapy service had been introducedto induce the labour of women whose pregnancy haspost dates in order to avoid medical induction of labour.

• A birth afterthought service is offered to support womenand families post fetal loss, during pre pregnancy




planning and the ante natal period and postbirth.Vaginal birth after caesarean section (VBACS)clinics were available to support women in their carepathway

Learning from complaints and concerns• People we spoke with knew how to raise concerns or

make a complaint. Staff told us that they encouragedpeople who use services, those close to them, or theirrepresentatives, to provide feedback about their care,although we noted response rates were low. Complaintsprocedures and ways to give feedback were available.

• We saw in recent meetings in August 2014 thatcomplaints were reviewed to encourage learning. Theattitude of some members of staff had been highlightedas a concern, which was corroborated by a patient weinterviewed during the inspection. The managers wereaware and action plans were in place to encourageimprovement.

Are maternity and gynaecology serviceswell-led?

Good –––

The majority of maternity staff understood the corporatevision, and also the maternity strategy for developing theservices at Hinchingbrooke Hospital. Risks at team andmanagement level were identified and acted upon., andstaff recognised their role within the risk managementsystem. The culture was open and transparent; staff wereclear where they were performing well, but also fully awareof areas for improvement, such as breastfeeding rates.

We found the midwifery leadership model encouragedco-operative, supportive relationships among staff, andcompassion towards people who use the service. Therewere good examples of staff and service user involvementin design and future developments for the maternity unit.Staff reported that the managers and supervisors ensuredthey felt respected, valued, supported and cared for. Staffcontributions and performance were recognized, andcelebrated, which is good practice.

Vision and strategy for this service• The senior executive team provided inspectors with a

statement of vision and values encompassing keyelements of the NHS constitution, such as compassion,

dignity, respect and equality, with quality a key priority.The majority of maternity staff understood the visionand strategy, and also the maternity strategy fordeveloping the service.

Governance, risk management and qualitymeasurement• We saw through meetings and staff consultation that

risks at team and management level were identified andcaptured, and staff recognised their role within the riskmanagement system. We saw examples ofrecommended actions such as for Post PartumHaemorrhage (PPH) -quarterly audits> 2000mls toensure appropriate actions and lessons learnt were fedback via skills drills and mandatory training. Anotherconcern was 48 incidents where non-compliance withpolicy was an incident cause. Non adherence andspecific trends were identified in the clinical riskmanagement bulletin July 2014 to raise staff awareness.

• Staff understood the views of patients about their care.Concerns or best practice were shared to improveperformance. We saw a user-friendly women’s healthstaff website, which provided full reports on riskmeetings, quality assurance practices, strategies, thetrust-wide 16 point plan for improvements, and practicechanges.

Leadership of service• The staff reported positive leadership from the head of

midwifery, who knew her staff, played to their strengths,and developed them as individuals within the midwiferyservice, which was noted as good practice.

Culture within the service• The culture was open and transparent; staff were clear

where they were performing well, but also aware ofareas for improvement, such as breastfeeding rates.There were no surprises; staff were consistent in whatthe key risks were, and this fitted with the current riskprofile for the maternity unit.

• Staff showed us the “stop the line” procedure whichanyone could initiate to stop and act immediately withthe team to rectify problems. Staff we spoke with notedthey would use if necessary but had not needed toinitiate to date.

• Staff were consulted on service designs and upgrades topremises through multidisciplinary meetings, focusgroups and emails. They were encouraged to be




involved in service developments, such as the design fora new bereavement suite, which also encouragedservice user involvement, which was noted as goodpractice.

Public and staff engagement• The bereavement steering group encouraged service

user attendance and participation in design andpolicies, as did the labour ward forum and MaternityServices Liaison Committee (MCSL) meetings, which wasnoted as good practice.

• We reported that the response rate to the Family andFriends Test was low; the results obtained showed that75-84% of women were extremely likely to recommendthe service, as of July 2014.

Innovation, improvement and sustainability• The trust is reviewing and considering alternative

maternity IT systems, to improve information systemsand records management, that are compatible with thepatient delivery system in place currently. Thecommunity teams would also benefit, as their currentelectronic information systems were limited.

• The maternity service could demonstrate that they weremonitoring capacity and forward planning. There hadbeen a drop in delivery rates in the last year, and thecommissioners are undertaking a 5 year planning reviewof the provision of maternity services across the threematernity units in their commissioning area.




Safe Requires improvement –––





Overall Requires improvement –––

Information about the serviceHinchingbrooke Hospital provides end of life carethroughout the trust, as there are no dedicated palliativecare beds. The hospital has a dedicated palliative careteam, which consists of three specialist nurses and apalliative care consultant. This team co-ordinate and plancare on the wards for patients at end of life, and areavailable Monday to Friday, 9am-5pm, excluding BankHolidays. Out-of-hours consultant support is provided bythe on-call medical consultant.

We inspected four wards where end of life care wasprovided; these were Apple Tree, Walnut, Juniper andCherry Tree Wards. We also visited the bereavement centre,the chapel of rest, and the mortuary. During our inspection,we spoke with 15 patients and relatives, and 34 membersof staff, including nurses, doctors, health care assistants,mortuary technicians, the chaplain, and staff in thebereavement centre. We also spoke with one of thespecialist palliative care nurses and the palliative careconsultant. We observed interactions between patients,their representatives and staff, considered theenvironment, and looked at care records. Before ourinspection, we reviewed performance information from,and about, the hospital.

Summary of findingsEnd of life care service require improvements aspatients are at risk of not receiving safe or effectivetreatment that meets their needs. Do not resuscitateforms were not completed correctly, the palliative careteam were over stretched which meant that staff werenot effectively trained and patients did not receive thelevels of care they could expect. These risks were notrecorded on a risk register as there was not one specificto end of life care. We were told that there were noassociated end of life care risks.

'Do not attempt cardio-pulmonary resuscitation' (DNACPR) forms were completed, but a high percentage hadnot been appropriately signed by a consultant. In manyinstances, we found that DNA CPR decisions had notbeen discussed with the patient or their representatives.Assessments had not been completed when the reasongiven for not discussing decisions with patients wasrecorded as the patient lacking capacity.Documentation was found to be poor throughout theservice. Ward staff training in end of life care waslacking, and no one we spoke to on the wards hadadvanced communication training, however thepalliative care team did have this training.

The specialist palliative care team was well-led, and hadworked hard to improve end of life care throughout thehospital. The team had put together a business case toincrease staffing within the team, in order to ensure that

Endoflifecare

End of life care


they could provide an equitable, effective and safe endof life care service, that was available 24 hours everyday. The chaplaincy service provided outstanding careto patients and support to the nursing staff on wards.

Most of the hospital wards were providing end of lifecare and therefore this report should be read inconjunction with the medical care report.

Are end of life care services safe?

Requires Improvement –––

End of life care took place on general ward areasthroughout the trust, and required improvement. Thespecialist palliative care team told us that they wereunder-resourced to be able to provide safe palliative care,and to roll-out education to equip staff on the ward toprovide safe and effective end of life care. 'Do not attemptcardio-pulmonary resuscitation' (DNA CPR) forms werecompleted, but 10 out of 15 we reviewed had not beenappropriately signed by a consultant. In many instances,we found that discussions relating to DNA CPR were notrecorded. It was therefore difficult to ascertain whetherDNA CPR discussions had taken place with patients or theirrepresentatives. We also found that these issues were notaddressed on any risk register.

We found that staff had received very little or no training inrelation to the Mental Capacity Act (MCA) and Deprivationof Liberty Safeguards (DoLS), and assessments had notalways been appropriately undertaken when a patient wassaid to lack capacity as a reason for not discussing DNACPR decisions with them. There was limited information incare plans. End of life care training had only just beenrolled out amongst staff within the trust, but the specialistpalliative care team were struggling to meet demand withtheir current resources.

Incidents• We spoke with one of the specialist palliative care

nurses about incident reporting in relation to end of lifecare. They said that they rarely reported incidentsrelating to end of life care, but gave an example of atime when they had ‘stopped the line’ because of poorstandards of care.

• There was no risk register specific to end of life care, andthe specialist palliative care team told us that therewere no identified risks in end of life care. However, thespecialist palliative care team also told us they wereunder-resourced and this could impact on the safety ofend of life care throughout the hospital.

Cleanliness, infection control and hygiene• We saw that staff in the mortuary had sufficient access

to personal protective equipment (PPE) and there wereadequate hand-washing facilities.

Endoflifecare

End of life care


• We saw that the mortuary was visibly clean.

Environment and equipment• Staff reported that equipment required to care for

patients at the end of their life was available when it wasneeded. Ambulatory syringe drivers were not kept onthe wards, but staff told us they could be accessed fromthe equipment library as required.

• The trust used ambulatory syringe drivers for patientswho required a continuous infusion to control theirsymptoms, and these met the current NHS PatientSafety guidance. This meant that patients wereprotected from harm when a syringe driver was used toadminister a continuous infusion of medication,because the syringe drivers used were tamperproof andhad the recommended alarm features.

Medicines• The trust had a comprehensive anticipatory prescribing

policy, and we were told by staff that patients whorequired end of life care were written up for anticipatorymedicines. (Anticipatory medicines are medicines thatare prescribed in case they are required.)

• The palliative care team gave advice on anticipatoryprescribing when it was required.

• We saw that anticipatory medicines were prescribedwhen they were required.

• The National Care of the Dying Audit May 2014 showedthat over half the patients treated by the trust werereceiving PRN (as required) medication for the five keysymptoms that may develop during the dying phase.

• The specialist palliative care team told us thatmedication could be accessed in a timely manner forpatients who had expressed a preference to die athome.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Throughout our inspection we looked at patientrecords. We found that in some instances, where DNACPR decisions had not been discussed with patients,this was documented as being because the patient didnot have capacity, and the reason given for this was thatthe patient was too unwell. We saw no evidence that amental capacity assessment had been undertaken inany of the patient records we looked at.

Records• Information Governance training was included in the

trust’s mandatory training programme.• We reviewed 15 'do not attempt cardio-pulmonary

resuscitation' (DNA CPR) forms throughout four of thewards we inspected. We found that DNA CPR forms werenot always completed in line with national guidancepublished by the General Medical Council (GMC). Wesaw that whilst all of the forms had been signed by ajunior doctor, ten of the forms had not beencountersigned by a consultant.

• We also saw that on nine occasion’s discussions aboutDNA CPR and levels of treatment had not beendocumented. Only on one occasion did we see thatceiling levels for treatment had been documented in thepatient’s notes. We were therefore unable to establishwhether discussions about DNA CPR and levels oftreatment had taken place with the patient or, wherethe patient lacked capacity, their representative.

• The trust undertook audits of DNA CPR forms. We sawthe audit from September 2013 to September 2014. Thisaudit showed that 66% of DNA CPR forms that had beencompleted had been discussed with either the patientor their family, and 41% of forms had a reason why nodiscussion had taken place with the patient or theirfamily. This was well below the trust’s expectedstandard of 100%.

• Ward staff were confused as to which documentationthey should be using to care for patients at the end oftheir life

Mandatory training• The National Care of the Dying Audit (May 2014) scored

trusts out of 20 for the continuing education, trainingand audit of staff in care of the dying. Eighteen per centof participating organisations, including this trust,scored zero compared to an England average of seven.The trust has told us that it had, in the week of ourinspection, implemented a training programme toaddress this deficit.

• End of life care training had not been included as part ofthe trusts mandatory training programme. However, thespecialist palliative care team told us that end of lifecare was going to be included for all new starters, andthat it was going to mandatory, as of September 2014.

• Staff we spoke with on the ward areas told us that theywould value more training on end of life care.

Endoflifecare

End of life care


• The specialist palliative care team told us that theywould like to provide more training but they alsorealised this was difficult due to under-resourcing withinthe team.

Management of deteriorating patients• The wards we inspected used a recognised early

warning tool to identify when patients weredeteriorating.

• Specialist support was available for staff on the wardsfrom the specialist palliative care nurse when required.Out-of-hours support could be accessed from theconsultant on-call.

• One of the specialist palliative care team told us thatthey review referrals, and urgent referrals were usuallyseen the same day.

Nursing staffing• The hospital specialist palliative care team at

Hinchingbrooke Hospital included three specialistpalliative care nurses, who were 2 whole timeequivalents (WTE). These nurses supported ward staff,who were delivering end of life care.

• These nurses provided support from 9am until 5pm,from Monday to Friday. It was felt that this wasinsufficient to support the needs of patients requiringend of life care, and a review had taken place to assessthe level of specialist palliative care nurses required toprovide a good quality end of life care service. At thetime of our inspection, a business case had beensubmitted for approval of another 2.5 WTE specialistpalliative care nurses at the hospital, in order to enablespecialist palliative care support 24 hours a day.

• Patients requiring end of life care were nursed ongeneral wards throughout the trust. Staff told us thatwards were regularly short staffed. One member of stafftold us that they felt staffing levels were at a minimumand that this was affecting patient care.

• The wards used high numbers of bank and agency staffto fill gaps in the rota which put patients at risk ofreceiving care that was not consistent.

• One of the specialist palliative care team told us thatthere were generally issues on a Monday morningfollowing no specialist cover over the weekend.

Medical staffing• The overall care of each patient was managed by the

consultant who was relevant to each patient’s condition.

• There was a 0.5 WTE specialist palliative careconsultant, who covered three sessions per week atHinchingbrooke Hospital. When the specialist palliativecare consultant was on annual leave or sick leave, therewas presently no specialist cover at this level. It was feltby the palliative care consultant that medical cover forthe palliative care team was insufficient, and a reviewhad taken place to assess the level of medical staffingrequired to provide a good quality end of life careservice. At the time of our inspection, a business casehad been submitted for approval for another specialistpalliative care consultant to cover another five sessionsat the hospital.

• Specialist palliative care advice about symptom controlwas not available out of hours. Out-of-hours adviceabout symptom control was available from theconsultant on-call rota, which covered several hospitals

Major incident awareness and training• The mortuary technicians told us that they had a

contingency plan in the event that the mortuarybecame full. The trust had an agreement with anotherhospital and with a local undertaker, and was aware ofthe circumstances under which they should use thisplan.

Are end of life care services effective?


End of life care services were not effective throughout thetrust and required improvement. Staff at ward level werenot competent in caring for people at the end of their life,because they had not received the training required toenable them to undertake this role. None of the staff atward level, or in the bereavement office and mortuary, hadreceived advanced communication training to enable themto have difficult conversations with patients or theirrepresentatives. Specialist palliative care nurses did havefurther training in this area. Staff did not always referpatients to the specialist palliative care team in a timelymanner, and the palliative care team told us that therewere often problems in relation to end of life care followingweekends when the team were unavailable. The trustsbereavement policy referred to the Liverpool Care Pathwaydespite this policy being updated in September 2014.The

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End of life care


trust were slow to roll out the Amber care bundle whichmeant that patients did not receive timely effective care asstaff were confused as to what the care pathways shouldbe.

The specialist palliative care team were not able to deliveran effective education programme, roll out initiatives, carefor patients and undertake the required audits with theresources they presently had. A business case had beendrawn up to expand the team, with a vision of providing an,effective and equitable 24 hour service, seven days a week.All of the staff we spoke with told us that the specialistpalliative care team were incredibly supportive and thatthey had a good presence.

Patient’s pain relief was prescribed and palliative carenurses were able to prescribe these medications. Patientsreported through the national care of the dying audit thatthe trust was performing well in this area from the patients’perspective.

Evidence-based care and treatment• The specialist palliative care team based the care they

provided on the NICE Quality Standard 13 – End of LifeCare for Adults. This quality standard defines bestpractice in end of life care for adults.

• Following the withdrawal of the Liverpool Care Pathway,the specialist palliative care team had introduced a carein the last days of life tool. This was a holistic tool whichincluded an initial medical assessment and an initialnursing assessment. However, not all staff we spoke toon the wards were aware of the tool, or whichdocumentation they should be using for patients at theend of their life.

• The trust had local guidelines and policies in place thatwere up to date and based on the NICE guidance.However, the trusts bereavement care policy had beenreviewed in September 2014, but still containedreference to the Liverpool Care Pathway as a relatedpolicy and procedure. This could be confusing for staff,as this pathway is no longer in use throughout the trust.Staff also told us that since the withdrawal of theLiverpool Care Pathway, they were not always surewhich documentation they should be using.

• A number of initiatives were being rolled out throughoutthe trust to support the NICE guidance. For example, theAMBER care bundle was being rolled out to support theidentification of patients with an uncertain recovery.This was being rolled out by a bank nurse just one day a

week. It was felt that this was insufficient to effectivelyroll out the AMBER care bundle and support staff toimplement it on the wards. At the time of our inspection,a business case had been submitted for approval of a1.0 WTE AMBER care facilitator.

Pain relief• There were clear guidelines for prescribing pain relief in

end of life care.• Nursing and medical staff told us that they would

contact the specialist palliative care team for adviceabout appropriate pain relief, if required.

• The specialist palliative care nurses were beingsupported to become nurse prescribers. One specialistpalliative nurse told us that the doctors were veryresponsive at prescribing their instructions.

Nutrition and hydration• The trust had participated in the National Care of the

Dying Audit (May 2014). The results showed that thetrust was identified as being better than the Englandnational average at reviewing patient’s nutrition andhydration requirements at the end of life. The Englandnational average for reviewing patient’s nutritionalrequirements was 41% and the trust scored 53%, andfor reviewing patient’s hydration requirements 50% andthe trust scored 70%.

• We saw that nutrition and hydration needs wereincluded in patients’ individual end of life carepathways.

Patient outcomes• The trust participated in the National Care of the Dying

Audit 2014. The results reflect what we found in thatreferral to the specialist team was delayed, educationand audit was poor and that a formal feedback processfor relatives was not in place.

• Preferred place of death was being audited, as it was aCQUIN for end of life care. (Commission for Quality andInnovation (CQUINs) are frameworks to improve qualityof service and better outcomes for patients.) A qualityaudit of patients preferred place of death had beenundertaken in December 2013. Of the 27 patientsincluded in the audit, 89% had expressed a preferencefor their place of death; 88% of these patients died intheir preferred place

Competent staff• The specialist palliative care team told us that six

members of staff had attended Quality End of Life Care

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End of life care


for All (QELCA) training, where they had spent five daysat St John’s Hospice. The aim of the QELCA programmewas to empower generalist nurses to return to their areaof work equipped to make a difference to the experienceof patients dying in hospitals and their relatives/carers.They were starting to identify staff who were passionateabout end of life care, to act as champions in the wardareas.

• With the exception of the specialist palliative care team,none of the staff we spoke with had received training orsupport with their communication skills, to enable themto be more confident in having discussions with patientsabout their end of life care. Specialist palliative carenurses have attended the Advanced CommunicationsCourse and have, alongside all Cancer Specialist Nursesand Consultants in the field of cancer, been trained toLevel 2 in psychological assessment.

• The specialist palliative care team were well supportedby their manager, and their nursing and medicalappraisals were up-to-date.

• The staff in the bereavement office had undertakentraining in counselling, one as long as 15 years ago, thestaff had not been supported to access advancedcommunication training.

Multidisciplinary working• The specialist palliative care team worked in a

collaborative and multidisciplinary manner.• Spiritual and religious support was available from the

chaplaincy team, and bereavement support wasavailable from the bereavement centre.

• There were regular multidisciplinary team meetings todiscuss patient care needs.

• The specialist palliative care team had good links withpalliative care services in the community.

• The trust used an electronic recording system to enablethe recording and sharing of people’s care preferencesand key details about their care. This ensured care wasco-ordinated and delivered in the right place, by theright person, at the right time.

• Staff told us that they knew they could get support fromthe specialist palliative care team if required.

• All of the staff we spoke with told us that the specialistpalliative care team were incredibly supportive and thatthey had a good presence.

Seven-day services• The specialist palliative care team were available

Monday to Friday, from 9am to 5pm.

• Out-of-hours advice about symptom control wasavailable from the consultant on-call rota, whichcovered several hospitals.

• The chaplaincy service provided 24 hour, on-callsupport seven days a week for staff, patients and theirrepresentatives.

Are end of life care services caring?

Good –––

Patients and their representatives generally spokepositively about the care they received. The specialistpalliative care team were passionate about the servicesthey provided, and recognised there was a need to improveend of life care services throughout the trust.

Chaplaincy staff were visible within the trust, and thechaplain told us that they could access religiousrepresentatives from all denominations as required. Staffaround the trust spoke highly of the support provided bythe chaplaincy team. The trust had a dedicatedbereavement office, where two bereavement officerssupported families through the formal processes followinga patient’s death. Staff in the bereavement office and themortuary demonstrated compassion and respect, whilepreserving the dignity and privacy of patients after death.The caring approach by the mortuary and bereavementstaff that we observed was outstanding. However .it wasnot clear through documentation that patients wereinvolved in the decision-making process at the end of theirlives, despite patients reporting through the patientssurvey that they were involved.

Compassionate care• Patients told us that they were generally happy with the

care they received. One patient told us “they [the staff]are dedicated to their jobs, some of them are angels”.

• Throughout our inspection we observed interactionsbetween staff and patients. Although we saw that somepatients were treated with dignity and respect, this wasnot consistent throughout the trust.

• The trust took part the 2014 National Care of the DyingAudit. The trust scored better than the England averagefor the indicator, 'health professional’s discussions withboth the patients and their relatives/friends regardingtheir recognition the patient is dying'.

Endoflifecare

End of life care


• During our inspection we visited the mortuary andspoke with the mortuary technicians. On discussion,staff were able to demonstrate compassion, respect andan understanding of preserving the dignity and privacyof patients following death.

• We visited the bereavement office and spoke with one ofthe bereavement officers and with chaplaincy staff, whodemonstrated compassion and respect for patients andtheir families. The trust may like to note that staffresponsible for supporting families post bereavementhad not undertaken any recent training to prepare themfor this role.

• We spoke with portering staff who were responsible fortransporting patients to the mortuary following death.The portering staff we spoke with were knowledgeableabout their responsibilities for ensuring patients weretreated with dignity and respect following death. Theportering staff we spoke with assured us that patientswere treated in a respectful and dignified manner atward level prior to being transferred to the hospitalmortuary.

• The mortuary staff we spoke with assured us that theyhad no concerns relating to the way in which patientshad been treated at ward level following their death.

Patient understanding and involvement• We could not ascertain that patients and their families

were involved in making decisions about their end of lifecare. We looked at 15 sets of patient records throughoutthe wards we inspected, and we saw that on nineoccasions discussions were not recorded that these hadtaken place with the patient or, where the patient lackedcapacity, their family.

• The trust took part in the National Care of the DyingAudit (May 2014). The results showed that the trust wasidentified as being above the England national averagewhich was 75% in relation to health professional’sdiscussions with both the patient and their relatives/friends regarding their recognition that the patient isdying. The survey also identified the trust as beingabove the England national average which was 64% forcommunication regarding the patient’s plan of care forthe dying phase.

• The specialist palliative care team told us that patientsat ward level were not always referred to them in atimely manner. This could compromise the patient’sopportunity to make decisions relating to end of lifecare, and their preferred place of care and death.

Emotional support• Although the specialist palliative care were trained in

advanced communication to ensure sensitivediscussions could take place, staff at ward level,including doctors were not. This meant that when thespecialist palliative care team were not available,patients, and those identified as being important tothem, may not have been given the opportunity to beinvolved in communication and decisions abouttreatment and care to the extent that the dying personwants.

• The chaplaincy staff offered bereavement support torelatives, as well as spiritual support to patients andfamilies, although this service was stretched to ensurethat a service could be provided 24 hours a day.

• The chaplaincy team also offered pastoral, emotionaland spiritual support to all staff throughout the trust.

Are end of life care services responsive?


Services at the end of patients’ lives were not alwaysresponsive to the individuals need. The referral criteria wasvague, and one of the specialist palliative care team told usthat patients were sometimes referred too late. We sawevidence of this on one of the wards we inspected. Thismeant that patients may not always receive the palliativesupport they require in a timely manner.

The specialist palliative care team was working hard toensure that every person receiving end of life care had apositive experience. Patients who were referred to thespecialist palliative care team were seen according to theirneeds. The specialist palliative care team told us that theywould always try to see urgent referrals the same day. Wewere informed of some areas of outstanding practice inrelation to the responsiveness of the chaplaincy serviceand bereavement services.

Service planning and delivery to meet the needs oflocal people• People requiring end of life care were cared for

throughout the trust. There were no designated beds orwards for patients who required end of life care.

Endoflifecare

End of life care


• Staff told us that they always tried to care for patientsrequiring end of life care in side rooms. During ourinspection we saw one patient who was dying in a baybecause the ward did not have a side room available.

• Staff told us that they would always try to accommodaterelatives where possible.

Access and flow• Patients requiring specialist palliative support were

referred to the specialist palliative care team by staff atward level. Not all staff were clear about the referralcriteria , and one of the specialist palliative care teamtold us that patients were sometimes referred too late.We saw evidence of this on one of the wards weinspected. This meant that patients may not alwaysreceive the palliative support they require in a timelymanner.

• One of the specialist palliative care team told us thatthere were often delays in seeing patients if they hadbeen referred over the weekend, and how quicklypatients could be seen would depend on how manyspecialist staff were in the hospital at the time.

• The specialist palliative care team had an expectationthat everyone who was dying should be referred tothem.

Meeting people’s individual needs• In A&E, the lead nurse had developed keepsake boxes

for when a child had died. In the boxes were candles,paper with seeds embedded so that family and carerscould plant them in memory of their loved one, clayprints to capture hand and foot prints, and othermemory items. These boxes were used throughout thehospital when needed, although sourced from A&E. Thenurse explained how they had raised the money to fundthe boxes through local supermarket charity initiatives.

• We visited the chapel and saw that it was set up to caterfor people of all faiths. The hospital’s chaplain told usthey had excellent links with representatives from allfaiths, and also supported people who did not have afaith.

• We saw that a memorial service took place within thechapel on the first Wednesday of every month forpeople who had experienced a pregnancy loss.Following the service, families were invited to join thechaplain for a walk to a memorial ribbon tree atHinchingbrooke Park, where they were given theopportunity to tie a ribbon on the oak tree.

• We saw there was a season’s garden by the chapel,which had been very carefully thought out to ensurethere was interest in the garden all year round. Thechaplain told us that patients and their families wereable to access the garden. However, we found that thegarden would not be accessible to patients who wereunable to get out of bed, as the entrance to the gardenwould not allow this.

• Staff in the bereavement office told us that they hadnumerous resources available to support people of allages and faiths following the death of a patient. We sawthey had numerous different books for children of allages who were bereaved.

• Discussions around preferred place of care and deathdid not always take place with patients. The palliativecare consultant told us that whilst staff were havingthese conversations with patients who had received adiagnosis of cancer, they were not always happeningwith patients who had other terminal conditions. It wasrecognised that this was an area that needed morework.

• One of the palliative care team told us that rapiddischarge planning was a problem if patients, who hadpreviously not had a package of care identified, wantedto be cared for and die at home. Although these patientswere fast tracked for continued health care funding, itcould take a long time to arrange packages of care. Thismeant that patients may not have always beendischarged to their preferred place of care in a timelymanner.

• Support was available for people living with dementia.• We did not see any patients who did not speak English,

but staff told us that translation services were availablewithin the hospital.

• Chaplaincy staff were visible within the trust, and thechaplain told us that they could access religiousrepresentatives from all denominations as required.Staff around the trust spoke highly of the supportprovided by the chaplaincy team.

• The trust had a dedicated bereavement office, wheretwo bereavement officers supported families throughthe formal processes following a patient’s death. Therewas a dedicated room where relatives could be seen inprivate.

Learning from complaints and concerns• The specialist palliative care team told us that they

rarely received complaints relating to end of life care.

Endoflifecare

End of life care


When complaints were raised, they were mainly aboutcommunication and lack of information. Staff were notable to provide us with any examples where learninghad taken place as a result of complaints relating to endof life care.

Are end of life care services well-led?

Good –––

The end of life care services were well-led. The specialistpalliative care team were a small, passionate anddedicated team. They had devised a business case todevelop end of life care services, and ensure that patientsand their families or carers had a good experience of care,and were given choices at the end of life. Although thespecialist palliative care team had a vision and strategy forend of life care within the trust, this had not beenformalised or shared throughout the trust, so staff in theward areas were not aware of the vision and values for endof life care.

At the time of our inspection, there was a plan to develop abereavement survey to engage the public in providingfeedback to improve services for end of life care.

There was a strong improvement culture within thespecialist palliative care team; services were beingdeveloped in line with national guidance, and there wasparticipation in national quality assessment to measureoutcomes. The specialist palliative care team were trying todo their best with the resources they had at their disposal.

Vision and strategy for this service• Although the specialist palliative care team had a vision

and values for end of life care, this was not written downor formalised, and had not been embedded amongststaff who were delivering end of life care at ward levelthroughout the trust. This had been partly due tounder-resourcing within the palliative care team.

• The specialist palliative care team had identified gaps inthe service offered and had prepared a business case todevelop a sustainable, safe palliative care service with24 hour access by December 2014.

• The trust was registered with the Transforming End ofLife Care in Acute Hospitals Programme. This was aprogramme aimed at improving end of life care within

acute hospitals. The specialist palliative care team hadworked hard to try to meet the key enablers, butexpressed that it was difficult without the resourcesrequired.

• The specialist palliative care team had attempted to rollout the AMBER care bundle across four wards. (TheAMBER Care Bundle is a tool that facilitatesdecision-making about patients whose condition isdeteriorating, and are clinically unstable, with anuncertain outcome. It provides a systematic approach tomanage the care of hospital patients who are facing anuncertain recovery, and who are at risk of dying in thenext one to two months.) This had proven difficultbecause the team were relying on a bank nurse todeliver training once a week. The business case hadrequested an AMBER Care Bundle facilitator and apalliative care discharge planner to cover a seven dayworking week.

• One of the specialist palliative care team told us that itwas difficult to deliver clinical care, education,undertake audits and work on strategic planning.

Governance, risk management and qualitymeasurement• We were told us that there was no specific risk register

for end of life care throughout the trust.• We saw that there was an action plan to develop and

improve end of life care services across the trust.• We saw that audits were taking place in line with

CQUINs that had been set for end of life care.• There was an end of life steering group, which was

attended by the medical director and met once amonth, and there was now a direct link with the trustboard.

Leadership of service• Locally, there was strong leadership within the specialist

palliative care team. The team was led by a palliativecare consultant, who was clear about what effective andsafe end of life services should look like. The team werepushing to improve access to palliative care fornon-cancer patients and generalist palliative care. Thespecialist palliative care team were, however, strugglingto role enable effective delivery of education to staff atward level, due to lack of resources. This had beenidentified, and a business plan had been drawn up toincrease the levels of specialist staff.

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End of life care


• All of the staff we spoke with were aware of thespecialist palliative care team, and spoke highly ofthem.

• The specialist end of life care team were passionateabout providing staff within the ward areas with thetools they needed to ensure patients and their familiesreceived a good end of life care experience.

• The palliative care consultant told us that their newmanager was responsive to the needs of the team.

Culture within the service• Staff we spoke with thought highly of the specialist

palliative care team. They spoke highly about theservice they provided.

• Staff reported positive working relationships with theteam.

• Staff within the specialist palliative care team spokepositively about the service they provided for patients,and expressed a desire to be able to provide a seven dayservice.

• The specialist palliative care team, the bereavementofficers, mortuary staff, and the Chaplains were veryproud of the difference they made to patients, and theirrelatives and friends.

Public and staff engagement• The specialist palliative care team were doing their best

to engage staff at ward level in end of life care training.• The specialist palliative care team told us that they were

developing a bereavement survey, so they could receiveongoing feedback on the experience of patients andcarers, to help ensure good care was identified, and sothat areas where improvements could be made wereacted upon.

Innovation, improvement and sustainability• The specialist palliative care team acknowledged that

there was work to be done to improve end of life careservices throughout the trust. A business case had beendeveloped to improve the staffing levels that wereneeded to sustain the service. Extra medical and nursingstaff were needed to continue to provide the servicelevels identified.

• The chaplain and the bereavement officer explained theplans to move the bereavement office nearer to themortuary, in order to lessen the need to travel through along hospital corridor to the viewing area.

• The bereavement officer told us that bereaved relativesdid not have to pay for car parking when they cameback to the hospital following the death of a patient.

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End of life care


Safe Good –––

Effective Not sufficient evidence to rate –––





Information about the serviceThe majority of clinics at Hinchingbrooke Hospital areprovided from the treatment centre, and saw 147,286patients last year. Some outpatient departments are alsolocated in the main hospital. Throughout the outpatientdepartment we inspected audiology, the diabetic clinic,ophthalmology, gynaecology, radiology, ear, nose andthroat (ENT), cardiology, trauma and orthopaedics. Inaddition to consultant-led clinics, there are nurse-ledclinics across a range of specialities. Outpatient clinics runfrom Monday to Friday.

During our inspection we spoke with 18 patients andrelatives. and 23 members of staff. including nurses, healthcare assistants, receptionists, the head of operations, andmedical staff. We observed interactions between patientsand staff, and considered the environment. Before ourinspection, we reviewed performance information from,and about the hospital.

Summary of findingsWe found outpatients to be safe. Medicines andprescription pads were securely stored, although wefound a small amount of medicines within the traumaand orthopaedic outpatient clinic, which were beingstored along with cleaning fluids and other items. Theoutpatient areas we visited were clean, and equipmentwas well maintained. Staff vacancies were beingmanaged appropriately. Patients were appropriatelyasked for their consent to procedures. On mostoccasions records were available for patient clinicappointments.

The service in outpatients was caring. Patients receivedcompassionate care, and were treated with dignity andrespect. The outpatient service was responsive topeople’s individual needs. Patients were seen withinnational waiting times. Staff told us that clinics wererarely cancelled. Translation services were available forpeople who did not speak English, and all the staff weasked about this were able to tell us how to accessthese services. Complaints were handled appropriately,and action was taken to improve the service. Outpatientservices were well-led and there was good localleadership of clinics. Patient feedback was used toimprove the service, and there was innovation in someservice areas, such as one-stop clinics in gynaecology.


Outpatients and diagnostic imaging


Are outpatient and diagnostic imagingservices safe?

Good –––

On the whole, we found outpatients to be safe. Medicinesand prescription pads were securely stored, although wefound that a small amount of medicines within the traumaand orthopaedic outpatient clinic were being stored alongwith cleaning fluids, methylated spirits, a lighter andbatteries. The outpatient areas we visited were clean, andequipment was well maintained. Staff vacancies werebeing managed appropriately. Patients were appropriatelyasked for consent to procedures. Staff told us that peoplewith complex needs would usually be accompanied by arelative or carer. If there were concerns about ability toconsent staff would contact their safeguarding lead.Records were generally available for patient’s clinicappointments.

Incidents• The trust had an electronic incident reporting system in

place. Staff said that they could access the hospital’sincident reporting system, and understood theirresponsibilities with regard to this. We were assured thatstaff were reporting incidents appropriately.

• There had been three serious incidents reported inoutpatients. Two related to radiology, and one to a drugincident. Action had been taken to address the issuesraised by these serious incidents through acomprehensive review of training and equipmentrequirements.

• Staff told us that they received feedback about incidentsthat had been reported. Any improvements to service oralterations to practice were implemented within thedepartment

Cleanliness, infection control and hygiene• Clinical areas were visibly clean throughout the

treatment centre.• We observed sufficient infection control equipment,

including gloves, aprons and hand sanitiser, throughoutthe department.

• We saw that equipment was cleaned between patients.

• Staff followed the hospital’s infection control policy. Weobserved staff regularly washing their hands, and usingpersonal protective equipment, such as gloves andaprons, when required.

• Staff adhered to the trusts ‘bare below the elbows’policy.

• We saw that infection control audits took placethroughout the department, and action plans were putin place if a problem was identified

Environment and equipment• The outpatient department was a purpose built

department with its own dedicated main entrance.• Public areas inside the department were modern and

well maintained.• There was generally enough seating in most areas, but

the department had identified problems with seating inthe cardiology outpatients area, as the seating was hardand uncomfortable.

• We observed that clinical and non-clinical areas wereuncluttered.

• Resuscitation equipment was immediately available foruse throughout the department, and checks were up todate for the equipment we inspected.

Medicines• Medicines and prescription pads were securely stored

and appropriately managed in most of the areas weinspected. The prescription pads were signed in and outand there were strict controls relating to who couldaccess them. They were signed in and out and checkedby two members of staff. One of which was the personauthorised to prescribe.

• However, we looked at the storage of medicines in theorthopaedic outpatients department, and found theywere being stored along with cleaning solutions,batteries and a lighter. This was escalated to the matronof the department, who told us that this was because oflack of storage. She assured us this would be rectified.

• We saw that fridge temperatures were checked andrecorded daily in all of the areas we inspected.

• There were no controlled drugs in any of the outpatientareas we inspected.

Records• Staff told us that it was unusual for them not to have

notes available when patients were seen in clinic.




• Patients confirmed that they had not experienced anyproblems with notes not being available for clinics.

• Staff confirmed that some information would beavailable electronically, so patients would always beseen if their notes were not available.

• The trust did not audit records within the department toassess whether they were always available for clinics.

• We saw that records in the clinic areas were keptsecurely, so that they could not be accessed by peoplewho do not have the authority to do so.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards• The staff we spoke with had not received any training in

relation to the Mental Capacity Act and the Deprivationof Liberty Safeguards (DoLS).

• Patients told us that staff always asked their permissionprior to undertaking procedures.

• We saw that staff gained consent from patients beforeundertaking procedures such as taking blood.

• We did not meet any patients within the outpatientdepartment who lacked the capacity to make decisionsthroughout our inspection

• Staff could contact the safeguarding lead if they had anyconcerns about patients in relation to consent andcapacity.

Safeguarding• Staff told us that they received safeguarding training.

Records we reviewed confirmed this.• There were up-to-date children’s safeguarding policies

and procedures in place, which incorporated relevantlegislation. Staff gave examples of when they had actedto safeguard children. We were assured that staff wereacting appropriately, and in accordance with nationalsafeguarding legislation. For example, we observed a listdetailing times when children had not attended theirappointments. The sister in one area showed usdocumentation and was able to clarify that appropriatesafeguarding practice had taken place.

• Staff were knowledgeable about their role insafeguarding, and confirmed that they had recentlyreceived safeguarding training. Records we reviewedconfirmed this.

• There was a team within the trust dedicated tochildren’s safeguarding. Staff said that the safeguardingteam were approachable and easily accessible. .

• Systems were in place to safeguard children. In thefracture clinic, a safeguarding screening tool was used

during initial assessments, which identified thosechildren at high risk. This tool had been implementedfollowing its successful use in the A&E department. In alloutpatient areas staff confirmed that they followed thetrust’s robust policy in relation to children who did notattend their appointment. Staff gave examples of whenthey had used this protocol, and confirmed that whenthere were subsequent concerns, they had liaised withthe child’s health visitor, school nurse or GPappropriately.

• The manager in the fracture clinic said that theyregularly attend the two monthly children’ssafeguarding meeting, which was led by the leadchildren’s safeguarding nurse Staff in other areas of thehospital which offered children’s outpatient servicesconfirmed that they did not have an opportunity to feedinto, or get information from these meetings.

Mandatory training• The outpatients department sat within the Eyes, Ears,

Nose and Throat (EENT) division. The records providedfor this department showed that over 95% of staff hadattended mandatory training apart from safeguardingadults training and equality and diversity. We wereunable to see figures for the outpatient departmentalone. However the matron told us that she monitoredtraining and ensured that people attended, thisaccorded with what we saw.

• The trust told us that they were aware of the need toimprove attendance at this training.The EENT divisionrecords showed that around 88% of staff had attendedthis training.

• Staff told us that they had received recent training inpaediatric cardio-pulmonary resuscitation (CPR).Records we reviewed confirmed this.

Nursing staffing• The outpatients department was staffed by a mix of

registered nurses and health care assistants. Each clinicwas generally run by one registered nurse and onehealth care assistant. Throughout our inspection of theoutpatient department, clinics were seen to be steady.Although staff told us that some clinics could be verybusy.

• There had been staffing shortages due to long-termsickness and compassionate leave. These shifts were




either being covered by the internal staff as overtime, orby bank staff. The department only used bank staff whowere known to them, and who had the particular skillsrequired of the clinic they were working in.

• Due to the expansion of the department, the ear, noseand throat (ENT) team had already recruited anadditional member of staff, in order to be fully staffed forthe relocation of the ENT service.

Medical staffing• Medical staffing was provided by the relevant speciality

running the clinics in outpatients. Medical staff were ofmixed grades. There was always a consultant to overseethe clinics, and junior staff felt supported.

Major incident awareness and training• There were business continuity plans in place to ensure

that the delivery of services was maintained.

Are outpatient and diagnostic imagingservices effective?

Not sufficient evidence to rate –––

We report on effectiveness for outpatients below. However,we are not currently confident that overall, CQC is able tocollect enough evidence to give a rating for effectiveness inthe outpatients department.

Evidence-based care and treatment• Clinical specialities worked in accordance with good

practice and national guidelines such as the NationalInstitute for Health and Care Excellence (NICE) guidance.

• Staff were aware of how to access policies andprocedures within their departments.

• Policies and procedures were updated regularly, andwere easily accessible to all staff. Staff demonstratedthat they practised evidence-based care. During ourinspection we were shown the pathway for primary andsecondary orthoptic vision screening assessments forchildren within the local area. We were assured that thisservice was reflecting national best-practice standardsas issued by the Royal College of Ophthalmologists.

Patient outcomes• The department was offering one-stop clinics in

hysteroscopy. This meant that patients could be seenquickly, assessed and treated, instead of having to waitfor results and come back to the hospital for treatment.

• New to follow-up patient ratios were benchmarkednationally, and indicated whether patients were beingeffectively managed, and if outpatient appointmentswere being used efficiently to reduce repeatedattendance. The new to follow-up ratios forHinchingbrooke Hospital were much better than theEngland average figures.

Competent staff• Training records confirmed that staff, including doctors,

had received an appraisal in the last year.• Staff on the reception desk told us that they had not

received any training in relation to communication skillsor conflict resolution, but often had to deal with peoplewho were upset.

• There were staff within the hysteroscopy clinic who hadreceived communication skills training to enable themto break difficult news to patients.

• Some staff, such as specialist nurses, had undertakentraining specific to their role.

Multidisciplinary working• We saw evidence of good collaborative multidisciplinary

team working in the diabetic clinic, where patients wereseen by a diabetic nurse, dietician and a podiatrist.

• Nurse-led clinics ran alongside consultant clinics.

Seven-day services• The outpatients department ran from Monday to Friday.

There were no evening or weekend clinics.

Are outpatient and diagnostic imagingservices caring?

Good –––

The service in outpatients was caring. Patients receivedcompassionate care, and were treated with dignity andrespect. Audits of privacy and dignity were taking placethroughout the department. Patients and relativescommented positively about the care provided from all ofthe outpatient’s staff.

Compassionate care• Throughout our inspection we saw patients being

treated with compassion, dignity and respect. We sawstaff were welcoming towards patients as they enteredthe department.




• We observed staff acting appropriately and kindlytowards children who were waiting in theophthalmology and fracture clinic.

• We saw that patients privacy and dignity wererespected. We saw staff knocking on clinic doors andwaiting to be invited to enter.

• Within the radiology department we saw that changingfacilities were separate for males and females. Therewere separate cubicles with curtains screened across tohelp to preserve privacy and dignity.

• Chaperones were available throughout the departmentas required, and their use was recorded by the clinician.

• We observed a patient who was distressed as they werechecking into the department. We were able to heareverything that was said by the patient and thereception staff. This meant that patients and theirconversations could be overheard in the reception areaof the department. Staff on reception told us that thiswas a problem if people were standing close to thedesk, and that they always tried to ask for minimalinformation to mitigate risks associated withconfidentiality.

• Matrons within the outpatients department wereauditing privacy and dignity throughout thedepartment.

Patient understanding and involvement• Throughout the service, patients and children said that

they felt involved, and understood the care andtreatment provided. One parent told us “the staffexplain everything”.

• We spoke with patients in the department, who told usthat they had been kept informed of their care and theplans for their future treatment. They told us that staffhad answered their questions and had given themenough time to discuss their care.

• We observed that patients were given time to discusstheir treatment and more time was allocated to patientswhere more sensitive information was discussed.

• Written information about their condition was readilyavailable for patients to take away.

Emotional support• We saw how a patient who was distressed was

supported in a very sensitive and respectful manner.• Patients we spoke with were positive about the support

they received from staff throughout the outpatientsdepartment.

• The staff we spoke with were all sensitive to thepotential for people to require emotional support whileattending the outpatients department, and knew of theareas within the department where that support mightbe required.

Are outpatient and diagnostic imagingservices responsive?

Good –––

The outpatients service was responsive to people’sindividual needs. Overall, patients were seen withinnational waiting times. Delays in clinics were explained topatients. Staff told us that clinics were rarely cancelled.There was support for people with a learning disability ordementia. Translation services were available for peoplewho did not speak English, and all the staff we asked aboutthis were able to tell us how to access these services.Complaints were handled appropriately, and action wastaken to improve the service.

Service planning and delivery to meet the needs oflocal people• There were plans in place to relocate ENT services to a

purpose-built ENT department, as clinic space waslimited due to the hospital taking on more serviceswithin the department. There was a business plan inplace, and the relocation was due to take place byDecember.

• Staff were supported by bank staff, as a very last resortto cover sick leave and compassionate leave. Thedepartment would only use bank staff that were knownto them. The department had recently recruited a newmember of staff ready to support the relocation of ENTservices.

Access and flow• Senior staff told us that the trust operated a strict six

weeks’ notice of cancellation of clinics. They also told usit was very rare for clinics to be cancelled, and they weretherefore not audited. However, information providedby the trust indicated that cancellation of clinics wasbeing monitored and these varied between clinics.

• The department ran a 'choose and book' service, whichgave patients a number of appointments from whichthey could choose. Patients could receive text remindersfor appointments if they so wished.




• Did not attend (DNA) rates for the trust were better thanthe England average.

• With an average of 99% the referral to treatment times(RTT) of 18 weeks and waiting times for the trust weregenerally better than the Operational Standard of 95%.However, the percentage of people waiting less that 62days from urgent GP referral to first treatment for allcancers had dropped below the England average by 8%in quarter 1 of 2014- 2015. The operations manager toldus that this related to urology breaches, which wereshared with another hospital.

• We saw that where clinics were overrunning, staff keptpatients informed.

• There had been problems with waiting times incardiology, and these had been reviewed, with an actionplan being drawn up to address the issue. The actionplan had been put into action and the changes werebeing monitored for effectiveness.

• The trust did not audit clinics to see whether theyregularly over ran.

Meeting people’s individual needs• Whilst some areas, such as ophthalmology and

radiology, had suitable separate waiting areas forchildren, including toys and a television, other areaswithin the hospital that provided children’s outpatientservices did not. Parents that we spoke with in theophthalmology outpatients and radiology area said “thewaiting rooms are great” and “just what is needed tokeep the children preoccupied whilst waiting”. Outsidethe fracture clinic the children’s waiting room hadminimal toys to keep children entertained or distractedwhilst waiting for treatment.In some areas we visitedchildren were given stickers, bravery awards, or teddiesafter they were seen.

• In some areas we visited, although not all, we observedappropriate and child-specific information leafletsabout certain conditions and treatment. For example, inthe ophthalmology outpatients department weobserved a leaflet entitled 'Your child’s first visit to theeye clinic'.

• During our visit we tracked the pathway of a childattending radiology who lived with severe learningdisabilities. We observed that the service had beenadapted to meet his specialist needs. For example,radiology had provided a specific appointment for thisperson, during a less busy period within thedepartment. We also observed that the service had

pre-planned the appointment, and had a hoist ready,together with a senior radiographer. This meant that thepatient did not have to wait and was cared for safely.The child’s parent told us “we come here a lot and theservice is always very good”.

• Staff within the department told us that there was aninterpreting service in the hospital, and they knew howto access this.

• We saw that leaflets could be obtained in differentlanguages, but could not be obtained in braille.

• People with mental health conditions or learningdisabilities were not flagged up prior to coming in toclinic. However, there was a learning disabilities linknurse within the hospital, who would let the outpatientsdepartment know if they were aware of any patientscoming in. There was a quiet room available if this wasrequired.

• Staff explained that patients with complex needs wereusually accompanied by carers or family members.Access was available for patients in wheelchairs or thosewho used walking aids.

• The environment in the outpatients department wasspacious and bright.

• We also found seating to be uncomfortable in theophthalmology department. We also observed thewaiting area to be insufficient within this department, asvisually impaired patients often brought another personalong with them when attending appointments.

• Patients were given a bleep so they could leave thedepartment for a coffee. They were alerted via the bleepwhen they were required to attend their appointment.There was a coffee shop, where patients could buyrefreshments, but refreshments were not offered in thedepartment.

• Bariatric equipment was available if it was required.• Staff were responsive to the emotional needs of

patients, and could contact the chaplain if this wasrequired.

• The outpatients department had a quiet room forpatients who may have received difficult news. We sawthat this was in use at the time of our inspection.

Learning from complaints and concerns• Staff told us that complaints were shared with them in

order that lessons could be learned. Staff also told usthat compliments were shared with them so they knewwhat they had done well.




Are outpatient and diagnostic imagingservices well-led?

Good –––

Outpatient services were well-led and there was good localleadership of clinics. There was a business plan to expandand relocate services. Patient feedback was used toimprove the service and there was innovation in someservice areas, such as one-stop clinics in gynaecology.

Vision and strategy for this service• The head of operations demonstrated a vision for the

future of the service, and was aware of the challenges itfaced.

• All of the staff we spoke with were aware of the vision forthe future of the service.

• We saw that there was a business plan for theredevelopment and relocation of services within theoutpatients department. There was a plan to relocatethe ENT department by December 2014.

Governance, risk management and qualitymeasurement• There was a separate risk register for individual

outpatient clinics, and risks were being appropriatelymonitored.

• Incident reporting and analysis was taking place.• There were local departmental audits happening within

the outpatients department, but there were no auditsthat encompassed the outpatients department as awhole.

Leadership of service• There were boards throughout the services we visited

which displayed photos of the local leadership teamwithin each department.

• We found that local leadership was good, staff weresupported in their role and staff told us that senior staffincluding the matrons would assist with clinics at busytimes.

• In each area we visited we found that there was anallocated lead professional for the children’s servicesbeing offered within that department.

• Staff told us they found their managers supportive andapproachable. All of the staff we spoke with told us theywere happy in their roles.

Culture within the service• In each area we spoke to the lead nurse or manager for

the service. All staff were professional, open and honestwith inspectors, and positive about working in theirdepartment. Staff acted in a professional manner, theywere polite and well-mannered to patients andinspectors. They were open about the areas they wereproud of and described what worked well within theirdepartment. They were also honest about the areas thatrequired improvement.

• There was a positive ethos and mutual respect observedbetween colleagues.

• The team worked well to support each other. They wereflexible and committed to providing a positive patientexperience.

Public and staff engagement• We observed that patient feedback systems, including

surveys, were available for patients and those caring forthem, throughout the services we visited.

• We observed interaction between patients, theirrepresentatives and staff. Staff were able to respond tothe needs of patients using the outpatients department.

Innovation, improvement and sustainability• The department had expanded, and had business plans

in place for redevelopment and relocation of services;staff within the department were aware of theredevelopment plans.

• Waiting times in the ophthalmology department couldbe long due to the nature of some of the investigations,and the waiting area could become congested. Patientswere given bleepers so they could go elsewhere in thehospital whilst they were waiting. They were called viatheir bleeper when they were due to be seen.




Outstanding practice

• In both maternity and critical care we noted good care,focused on patients’ needs, meeting nationalstandards.

• The paediatric specialist nurse in the emergencydepartment was dynamic and motivated in supportingchildren and parents. This was seen through theengagement of children in the local community, in aproject to develop an understanding of the hospitalfrom a child’s perspective, through the '999 club'.

• The support that the chaplaincy staff gave to patientsand hospital staff was outstanding. The chaplain had agood relationship with the staff, and was consideredone of the team. The number of initiatives set up bythe chaplain to support patients was outstanding.

Areas for improvement

Action the hospital MUST take to improve

• Ensure all patients health and safety is safeguarded,including ensuring that call bells are answered in orderto meet patients’ needs in respect of dignity, andpatient’s nutrition and hydration needs are adequatelymonitored and responded to.

• Ensure that staffing levels and skill mix on wards isreviewed and the high usage of agency and bank staffto ensure that numbers and competencies areappropriate to deliver the level of care HinchingbrookeHospital requires.

• Ensure that the arrangements for the provision ofservices to children in A&E, operating theatres andoutpatients areas provided by the trust, is reviewed toensure that it meets their needs, and that staff havethe appropriate support to raise issues on the serviceprovision.

• Ensure records, including risk assessments, arecompleted, updated and reflective of the needs ofpatients.

• Ensure the care pathways, including peadiatricpathways, in place are consistently followed by staff.

• Ensure an adequate skill mix in the emergencydepartment and theatres to ensure that paediatricpatients receive a service that meets their needs in atimely manner.

• Ensure that there are sufficient appropriately skillednursing staff on medical and surgical wards to meetpatients’ needs in a timely manner.

• Ensure medicines are stored securely andadministered correctly.

• Improve infection control measures in the Emergencydepartment and medical wards to protect patientsfrom infection through cross contamination.

• Ensure staff are trained in, and have knowledge oftheir responsibilities under the Mental Capacity Act(MCA) 2005 and Deprivation of Liberty Safeguards(DoLS).

• Ensure that patients are treated with dignity andrespect.

• Ensure that all staff are adequately supported throughappraisal, supervision and training to deliver care topatients.

• Ensure pressure ulcer care is consistently provided inaccordance with National Institute for Health and CareExcellence (NICE) guideline CG:179.

• Ensure that catheter and intravenous (IV) care isundertaken in accordance with best practiceguidelines.

• Ensure patients are treated in accordance with theMental Capacity Act 2005.

• Ensure that the staff to patient ratio is adjusted toreflect changing patient dependency.

• Review the ‘Stop the Line’ procedures and whistleblowing procedures, to improve and drive an openculture within the trust.

• Standardise and improve the dissemination of lessonslearnt from incidents to support the improvement ofthe provision of high quality care for all patients.

• Ensure that all appropriate patients receive timelyreferral to the palliative care service.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


• Ensure action is taken to improve the communicationwith patients, to ensure that they are involved indecision-making in relation to, their care treatment,and that these discussions are reflected in care plans.

• Review mechanisms for using feedback from patients,so that the quality of service improves.

Action the hospital SHOULD take to improve

• Review the checking of resuscitation equipment in theA&E department, and across the trust, to ensure that itoccurs as per policy.

• Take action to reduce the overburdensomeadministration processes when admitting patients intothe acute assessment unit (AAU).

• Review intentional rounding checks to ensure thatthey cover requirements for meeting patient’s nutritionand hydration needs.

• Involve patients in making decisions about their carein the A&E department.

• Review the training given to staff, and the environmentprovided, for having difficult discussions with patients.

• Review translation usage in A&E, to ensure thatpatients receive information appropriate to theirneeds.

• Provide adequate training on caring for patients livingwith dementia, to improve the service to patientsliving with dementia.

• Discontinue the practice of adapting day rooms inrehabilitation wards to use as additional inpatient bedspaces.

• Review the clinical pathways for termination ofpregnancies in the acute medical area.

• Review the policy on moving patients late at night.• Review the out-of-hours arrangements for diagnostic

services, such as radiology and pathology, to ensurethat patients receive a timely service.

• Review mechanisms for fast track discharge, so thatterminally ill patients die in a place of their choice.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


Action we have told the provider to takeThe table below shows the essential standards of quality and safety that were not being met. The provider must send CQCa report that says what action they are going to take to meet these essential standards.

Regulated activity

Assessment or medical treatment for persons detainedunder the Mental Health Act 1983

Diagnostic and screening procedures

Surgical procedures

Termination of pregnancies

Treatment of disease, disorder or injury

Regulation 22 HSCA 2008 (Regulated Activities) Regulations2010 Staffing

There were insufficient numbers of staff with therequired skills, experience and knowledge to meet theneeds of patients. For instance:

In A&E, there were insufficient paediatric nurses tomaintain 24 hour cover for children using the service.

Inflexible staffing arrangements were in place in themedical directorate to meet the needs of patients.

There was a lack of staff, particularly on night duty, tomeet the needs of patients in the surgical wards.

In critical care, the level of staffing currently in placewould have enabled six level 1 patients at any one time.The unit had nine beds; there was a lack of agency andbank staff to flex the numbers of nursing staff to care forpatients.

The palliative care team could only support patientsbetween the hours of 9am and 5pm during the weekdaysdue to staffing levels.

Regulated activity



Surgical procedures



Regulation 9 HSCA 2008 (Regulated Activities) Regulations2010 Care and welfare of people who use services

The provider is failing to take proper steps to ensure thatcare plans are in place, which are regularly updated toreflect service users changing care needs, so that serviceusers are receiving care that is appropriate and safe.

The provider is failing to carry out assessment of needsto ensure that the care delivered meets their needs andis planned for.

Regulation

Regulation

This section is primarily information for the provider

Compliance actionsComplianceactions


The provider is failing to plan and deliver care that meetsthe needs of service users who are at risk due to pressurearea, catheter care, intravenous (IV) care and the risksassociated with bed rails.

Regulated activity



Maternity and midwifery services

Surgical procedures



Regulation 10 HSCA 2008 (Regulated Activities) Regulations2010 Assessing and monitoring the quality of serviceproviders

The provider is failing to take proper steps to implementa safeguarding system that protects service users fromthe risk of harm.

The provider must ensure that all complaints areidentified and responded to in a timely manner.

The provider is failing to implement an effective qualityand monitoring system to identify potentialnon-compliance within the service to improve itsdelivery and provide care that is safe.

Regulated activity



Surgical procedures


Regulation 11 HSCA 2008 (Regulated Activities) Regulations2010 Safeguarding people who use services from abuse

The provider is failing to take proper steps to identify thepossibility of abuse and put measures in place to preventit before it occurs.

The provider must ensure that they take proper steps torespond to any allegation of abuse.

The provider is failing to ensure that when any form ofcontrol or restraint is used in the carrying on of theregulated activity, that they have suitable arrangementsin place to protect service users against the risk of suchcontrol or restraint being unlawful.

The provider is failing to ensure that staff employed tosupport them to carry on the regulated activity havebeen trained in the use of ethical control and restraint.

Regulation

Regulation




Regulated activity




Surgical procedures



Regulation 12 HSCA 2008 (Regulated Activities) Regulations2010 Cleanliness and infection control

The provider is failing criterion 2.1 of the Health andSocial Care Act 2008 Code of Practice On The PreventionAnd Control Of Infections And Related Guidance. Undercriterion 2.1, with a view to minimising the risk ofinfection, the trust failed to ensure that staff wereadopting good infection control techniques and handwashing between patients, including patients withestablished C. difficile.

We found staff were not washing their hands in A&EApple Tree ward, Cherry Tree ward, Walnut ward and inthe Treatment Centre.

Regulated activity


Surgical procedures


Regulation 17 HSCA 2008 (Regulated Activities) Regulations2010 Respecting and involving people who use services

The provider is failing to ensure the dignity of serviceusers. The provider, in relation to Apple Tree Ward andJuniper Ward, is failing to treat service users withconsideration and respect.

Regulated activity




Surgical procedures



Regulation 20 HSCA 2008 (Regulated Activities) Regulations2010 Records

The provider is failing to ensure that records that pertainto the care of patients accurately reflect their care andtreatment plans. Records were completed to a poorstandard, with gaps and omissions in care plans and riskassessments found throughout medicine, emergencyand surgery areas.

Regulation

Regulation

Regulation




hinchingbrooke health care nhs trust hinchingbrooke hospital

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